COMMENTARY

Robotic-Assisted PCI: Time to Jump to the Joystick?

Gayatri Acharya, MD; Gurpreet Sandhu, MD

Disclosures

September 26, 2016

Editorial Collaboration

Medscape &

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Gayatri Acharya, MD: Greetings. I'm Dr Gayatri Acharya, cardiology fellow at Mayo Clinic. Today, we'll be discussing robotic percutaneous coronary interventions (PCIs). I'm joined by my colleague, Dr Gurpreet Sandhu, director of the cardiac catheterization lab at Mayo Clinic. Welcome, Dr Sandhu.

Gurpreet Sandhu, MD: Thank you, Gayatri. This is a great topic to be discussing today.

Safety and Efficacy of Robotic-Assisted PCI

Dr Acharya: We've seen that robotic percutaneous coronary intervention has already been introduced into the interventional cardiology lab, but what are the benefits to the operator?

Dr Sandhu: This is very promising new technology, and the biggest benefit I think that we will see will be improved safety in the cath lab. As you know, right now we are exposed to radiation doses constantly across our entire lifetime in the lab. So this will help reduce radiation exposure for the interventionalists as well as other personnel. Also, there is a high risk of orthopedic injuries from wearing heavy lead aprons. If we can get rid of those, that would be helpful as well.

Dr Acharya: That sounds very promising. When we think about benefits to the operator, we also think about benefits to the patient. So what benefits will we see for patient safety?

Dr Sandhu: At this time, the studies are still early stage.[1,2,3] They are small studies that have mostly focused on feasibility, and we don't have enough data regarding outcomes of patient safety. The technology, also at this point, permits use of just a single wire and a single device such as a balloon or a stent. So, the lesions addressed are also reasonably straightforward. I think it will be a while before we actually see any outcomes data.

Dr Acharya: What do we know so far about the efficacy of using robotic PCI?

Dr Sandhu: With this technology, it is a cassette that allows you to manipulate a wire and also allows you to advance and withdraw a stent or a balloon. So in terms of efficacy, this can treat straightforward lesions: type A/type B. But anytime you're looking at complex bifurcation, [chronic total occlusions] CTOs, where you need additional guide support or a second wire or second device, in those areas it can't be used in its current format.

Learning Robotic PCI and Bringing It to Mainstream

Dr Acharya: As a fellow, it's of great interest to me to know what skill set I'll need to operate this technology. How does the technology learning curve differ from that of traditional PCI?

Dr Sandhu: I would say from a fellow's perspective and from a trainee perspective, this doesn't provide you the same tactile feedback as you get with a manual PCI. Also, the technology has joysticks as opposed to what I would consider normal hand movements, as you see with other robotic devices. So, from a learning perspective for a trainee, it's best to learn manually first. But for an experienced interventionalist, I think five or six cases are probably all you need in terms of overcoming the learning curve.

Dr Acharya: When we think of incorporating this into labs across the country, what sort of infrastructure changes will be required to make this more mainstream?

Dr Sandhu: The infrastructure changes in our case were actually pretty simple. The most we needed was space to park the actual cabinet, or the "cockpit" as they call it, and then we had to pull some additional wiring to integrate it with our existing systems.

Dr Acharya: When we think about making changes to the infrastructure, incorporating new technology for patients, how will this impact healthcare costs?

Dr Sandhu: That is a critical question and a very important question. Anytime you bring in a new technology, it costs, as you know, several hundred thousand just to get the device in. And then with each procedure that you do, there's probably an additional thousand dollars of expense that currently is not reimbursed, and this will be an issue. However, if you weigh this against the safety of the operators and the safety of the other personnel in the lab, I think it will balance out over time.

Dr Acharya: And that seems to be a very critical balance to strike, given that interventionalists do this for many years of their lives.

Dr Sandhu: Absolutely.

Looking Forward: Applications and Improvements

Dr Acharya: Are there any other applications to this technology?

Dr Sandhu: I can foresee some futuristic applications. At this time, you have to be physically present inside a room to do an intervention, but what about remote human habitations? How about large cruise ships where you have someone who has an MI and there are no personnel available or no easy transportation facilities? Potentially with this, what you could foresee is if you have any medical personnel capable of putting in a central line or putting in a sheath in an artery, you could do remote PCI from a distance and use this as a lifesaving technology.

Dr Acharya: That would be a great application as we go forward and improve on this technology. Are there any other improvements that need to be made to this technology before we make it more mainstream?

Dr Sandhu: I think, realistically, what we need is an ability to control more devices. Besides more devices, we need predictive capabilities, more computerized interfaces to predict a lesion type, automatically advance a wire or a device, and be able to improve patient outcomes.

Dr Acharya: Thank you, Dr Sandhu. Any other thoughts on this topic?

Dr Sandhu: No, this was great, Gayatri. It was wonderful to discuss this today. Thank you.

Dr Acharya: Great. Well, thank you for those very important insights, and thank you for joining us on theheart.org on Medscape.

Dr Sandhu: Thank you.

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