St. John Hospital & Medical Center, a member of the St. John Providence Health System, is the first in Michigan to combine the medical expertise of an operating room with the know-how of a cardiac cath lab.
Located in Detroit, the Gretchen C. Valade Hybrid Cardiovascular Operating Room is designed to diagnose and treat heart valve disease and support minimally invasive surgical procedures, such as Trans Catheter Aortic Valve Implementation (TAVI).
The TAVI procedure is an alternative choice for high risk patients unable to undergo the rigors of traditional open heart surgery due to advanced age, renal disease, lung disease, arrhythmias, diabetes and other underlying disease, according to Antonio (Tony) DelVillano, MSHA, BSN, RN, Manager for Cardiac Vascular Services (Cardiac Cath Lab, Electrophysiology, Cardiac Rehab and Pre and Post-Operative Patient Care Services).
"Our hybrid OR combines the imaging and hemodynamic monitoring of a cath lab with the functionality of an operating room," DelVillano said.
Amy Blowycky, BSN, RN, CNOR, a Cardiovascular and Thoracic Specialist and Manager for the OR's Open Heart Nursing Team, said, "The Hybrid OR incorporates the catherization capabilities of a cath lab, the sterile environment of an OR and enhances it further by adding advanced computerized radiological imaging (CR)."
Merging Skills & Expertise
Trans catheter aortic valve replacement (TAVR) procedures merge the cardiologist's percutaneous catheter skills with the surgeon's expertise to form a team of two heart experts, an operative innovation that works well "because cardiac surgeons aren't as familiar with catheter work and cardiologists don't perform heart surgery," DelVillano said.
At the onset of the procedure instead of cutting through the sternum to open the patient's chest, as done during traditional valve replacement, the cardiac surgeon punctures the skin into one of several arteries (femoral, subclavian or directly into the aorta).
"The direct aortic approach requires the use of an 18-F (French) catheter that's guided through the artery up and around the arch of the heart and into the heart," Blowycky said. "At that point the replacement device is strategically positioned to be deployed to the correct site through the catheter."
Supported by a protective sheath (a metal-mesh tube) and warmed to room temperature the device is inserted into a patient's artery where a guide wire moves it into the body and into the heart.
The cardiologist and cardiac surgeon then place the device into the heart by threading it through the catheter where it inflates inside the patient's existing valve. Mounted on a self-expandable metal stent the replacement valve is then crimped or pressed down so that it's compatible with the 18-F catheter delivery tool.
Pivotal Nursing Roles
GRAND OPENING: Nurses at St. John Hospital & Medical Center, Detroit, prepare a valve for insertion into a cardiac patient in the first-ever procedure in the facility's new hybrid OR/cath lab. ADVANCE thanks the hospital.
The Open Heart OR Nursing Team prepares patients for surgery as they would for open heart surgery.
The patient is prepped from head to foot and a drape is placed over the upper chest, for example, while similar infection control and safety protocols are followed throughout the procedure.
Nurses assist the surgeon and function as scrub nurses and circulating nurses during the TAVR procedure. Prior to the procedure OR nurses set up three surgical tables, according to Blowycky.
The main table includes lead wires and introducers that gain access to the artery and function as a port. A second table is set up to keep the valve replacement device cold and retracted through a delivery device loaded with ice, and the third table is arranged for the actual procedure.
Also, in case of an emergency a surgical set up is prepared and ready to use should open heart surgery be required.
A core group of Cardiac Cath Lab nurses who are familiar with the procedure assist the cardiologist. And nurses are also responsible for hemodynamic monitoring, DelVillano said.
"This process records patients' internal blood pressure and heart rate and calculates changes in blood pressure differences on both sides of the heart valve, so it's an important tool during trans catheter valve replacements," he said. "Measuring pressure differences across the valve lets us know how well a patient is tolerating the procedure and if he or she is receiving optimal treatment.
"This goal is achieved when the systolic blood pressure across the normal valve is the same on both sides, in the left ventricle and in the aorta," DelVillano contnued.
"In situations when the valve is severely stenosed (hardened), the systolic pressure in the left ventricle is higher than in the aorta," he explained. "However, once the correct size valve replacement device is deployed and working well we see an immediate return of equal (or almost equal) systolic blood pressure on both sides of the valve."
Multitasking Nurses Required
In addition to being skilled in catheter use and hemodynamic monitoring, cath lab nurses do diagnostic testing and are involved in diagnosing peripheral problems, while also assisting with other surgical procedures, such as angioplasty and stenting in the legs.
"The Electrophysiology Department is a part of the Cath Lab Department where electrophysiology nurses assist with electrophysiology testing and catheter ablation (burning of the pathways that cause electrical disturbances in the heart)," DelVillano said.
"EP nurses assist cardiologists with placement of implantable cardiac defibrillators and pacemaker insertion," he said. "Basically the Cath Lab does the plumbing work and the electrophysiology lab does the electrical work."
Joan Fox Rose is a frequent contributor to ADVANCE.