The Robot Will Echo You Now: Remote CV Imaging Edges Closer

Shelley Wood

August 13, 2014

NEW YORK, NY — Echocardiography researchers have successfully performed ultrasound exams using a robotic arm controlled via the internet on patients located at remote locations—and in one case, on the other side of the Atlantic.

One study used the robotic device to perform echocardiography on patients at a rural location in Sweden, with remote consultation at a tertiary hospital located 135 miles away, and compared the "diagnostic process" with that of the standard of care, which involved traveling to the tertiary hospital for consultation[1].

A second paper looked specifically at real-time navigation of the arm over a larger distance, using a nondedicated internet connection[2].

Both are published in the August 2014 issue of JACC: Cardiovascular Imaging.

Dr Partho Sengupta (Icahn School of Medicine, New York, NY), lead author on the latter paper and coauthor on the former, says these first-in-human studies are an important first step.

"Robotic arms have been used in the past for long-distance surgical applications, and ultrasound has been used with some of these," he told heartwire in an email. "What is new is the type of robotic arm—low weight and portable, [with] the ability to obtain images over local internet connections—no need for dedicated lines. To the best of our knowledge, this application over such a long distance (transatlantic) and with the use of nondedicated lines has not been performed in the past."

The studies employed a lightweight, custom-made, robotic arm fitted with an ultrasound transducer operated by remote sonographers, either at the tertiary center in Sweden in the paper by Dr Kurt Boman (Umeå University, Sweden) et al, or in the low-bandwidth study by Sengupta et al, in New York, NY, and Munich, Germany, with a patient volunteer located in Burlington, MA.

In the Swedish study, total diagnostic process time in a series of heart-failure patients was significantly reduced from 114 to 27 days in those patients receiving remote consultation. Moreover, delay to obtaining a specialist consultation was reduced from 86 to 12 days in the remote-imaging arm. Patients were also more satisfied with the remote exam, citing the lack of travel time.

In the transatlantic study, Sengupta and colleagues demonstrated that both a highly trained sonographer with a trainee could perform remote carotid ultrasound scans on a remote "patient" volunteer, localizing and visualizing the common carotid artery along its short axis and along its long axis with a total procedural time of four minutes. Experienced operators tended to adjust to the telerobotic techniques faster, but both inexperienced trainees and experts were able to learn the process swiftly, using simulator "phantoms."

In an accompanying editorial[3], Dr Sherif Nagueh (Methodist DeBakey Heart and Vascular Center, Houston, TX) pointed out that neither paper includes details on image quality obtained by the robotic arm. In the Swedish analysis, several patients had already undergone transthoracic imaging before inclusion in the study, but no analysis was provided as to how the remote imaging results compared with the previous test.

"Both studies present data showing potentially exciting opportunities for extending the application of cardiovascular ultrasound." Nagueh added in a press release issued by Mount Sinai, "These studies lift robotic imaging and telemedicine to the next level." Next steps will be to determine whether remote imaging has an impact on earlier diagnosis, treatment, and outcomes, Nagueh elaborated in the editorial.

Also commenting on the studies in a press release, Dr Valentin Fuster (Mount Sinai Heart, New York, NY) observed, "In clinical medicine, the use of more portable low-cost, safe, non–radiation-using ultrasound imaging technology is growing for diagnosis, patient monitoring, and procedural and surgical planning. The technology may be key to accelerating greater local and global healthcare access more efficiently and cost-effectively for patients, doctors, communities, and hospitals in need."

To heartwire , Sengupta stressed that telerobotic echo would be useful both for rural or remote locations in first-world countries, but also in the developing world.

"Ultrasound is the most cost-effective diagnostic tool for cardiovascular evaluations, [but] one of the challenges is related to the lack of technical expertise for performing ultrasound in remote locations. The current study suggests that this limitation can be overcome by having experts use robotic arms. This can reduce time to diagnosis and potentially impact outcomes in disease states where the timing of therapeutic interventions plays a big role in optimizing therapeutic outcomes."

Robotic ultrasound could also play an important role at a local level, in hospitals where physicians are performing protracted procedures that require ultrasound guidance. Here, he said, "robotic arms can also be useful hands for sonographers when prolonged imaging can lead to fatigue [and] cramps, thereby [affecting] imaging quality."

The impact of robotic ultrasound may be even greater in lower-income countries, Sengupta continued, noting that only 5% of the world's population has access to ultrasound. He responded to heartwire 's request for an interview from Bangalore, India, where he is coleading an American Society of Echocardiography Foundation humanitarian mission, broadcasting "learning sessions" for Indian physicians conducting echocardiography exams, with live input from imaging experts in the US.

"At the Bangalore Institute here, they already have a telemedicine department, and they are using cardiac ultrasound for long-distance patient referral, [but] they currently use a primitive platform for communicating and archiving images. The arrival of robotic ultrasound system will be a great asset for such programs and institutions."

Sengupta holds a licensed patent on "Method for Imaging Intracavitary Blood Flow Patterns" and is an advisor to Saffron Technology, Medical Intelligence, and TeleHealthRobotics and a consultant to Edward Lifesciences. Boman has a consultancy agreement with the robot manufacturer Mobile Robotics Sweden. Disclosures for the coauthors are listed in the paper.

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