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The evolution of robotic applications for intracardiac and endovascular procedures
Robotic applications in CV medicine began with cardiac surgery, but have recently become available for cardiac electrophysiology, as well as for percutaneous coronary and periopheral interventions.
In cardiac surgery, robotic-assisted procedures provide precise and efficient surgical manipulations in small spaces, often reducing the size of the operative incision. Recent advances in the availability of robotic systems were made with the primary goal to inprove precision. All invasive robotic cardiology systems are characterized by remote, precise, operator-directed delivery of catheters, guidewides and devices in the cardiac and vascular spaces.
Available technologies
Historically, an early robotic approach to invasive cardiology was introduced by Stereotaxis with a magnetic guidance system for intravascular and intracardiac guidewire tip manipulation. The Stereotaxis approach was principally applied to electrophysiology procedures for ablation catheter placement. The system utilizes large stationary magnets, which can provide a space issue in smaller laboratories and other laboratory equipment needed to be adapted to a magnetic safe environment.
George W.
Vetrovec
Hansen Medical developed a non-remote guidewire securable system for electrophysiology ablation. The goal is to make catheter tip placement more precise in a relatively open space (atrium and pulmonary veins).
Most recently, a robotic system specifically adapted for PCI was introduced by Corindus. The CorPath System allows the operator to remotely steer and advance the guidewire and to remotely control balloon or stent device delivery using a joystick system while sitting in a remote, radiation-shielded console during PCI. This system provides separate one-to-one control of guidewire rotation as well as variations in advancement or retraction speeds down to 1 mm stepped movement for both guidewire or device delivery. The guidewire is fixed during balloon or stent delivery facilitating safe, rapid delivery even in tortuous anatomy. The system is compatible with all standard devices. Future designs will include robotic guide catheter manipulation in addition to the current robotic delivery technology.
Procedural success, benefits
Technical robotic procedure success has been assessed. In the pivotal, FDA-approval PRECISE study, the CorPath System was associated with a 98.9% device success rate, with only two of 164 procedures being converted to manual because of inability to complete the procedure robotically. Furthermore, operator radiation was reduced by 95% compared with levels measured at the usual operator position tableside.
The benefits of robotic technology are numerous and include:
- Visualization: The operator sits directly in front of an imaging screen that provides much better visualization and actual anatomy for guidewire manipulation.
- Precision: The guidewire is manipulated with fine, precise control. In addition, the guidewire can be used to measure the true, 3-D length of a lesion, allowing optimal choice of stent length. Overall, the potential is to optimize PCI results across the diverse operator population, eliminating some of the presumed disparities related to case volumes.
- Operator safety: This includes both orthopedic and radiation operator risk. There are multiple reports of orthopedic, particularly back, injury associated with the weight of wearing radiation protection. Likewise concerns continue to grow regarding operator cancer risk from chronic procedure related exposure to radiation.
- Potential additional benefits: With greater operator precision, other potential patient advantages include reduced procedure times, including less contrast and patient radiation. Specific studies still must be done to document these specific benefits.
Future applications, growing potential
Future applications include peripheral interventions now available via the Hansen system, with the Corindus system likely to follow. Very intriguing is the potential for experienced operators to assist in the performance of unexpectedly complex primary STEMI PCI at remote locations. Longer-term, newer systems can be adapted for structural cardiac and additional electrophysiology applications.
In summary, robotic cardiovascular applications are growing with the potential to significantly improve precision, quality and safety.
George W. Vetrovec, MD, is the Harold and Martha Kimmerling Professor of Medicine at VCU Pauley Heart Center, Virginia Commonwealth University. He is also a member of the Intervention section of the Cardiology Today Editorial Board. He can be reached at VCU Medical Center, Box 980036, Richmond, VA 23298; email: gvetrovec@mcvh-vcu.edu.
Disclosure: Vetrovec reports no relevant financial disclosures.