REVIEWS Robotic technology in cardiovascular medicine Johannes Bonatti, George Vetrovec, Celia Riga, Oussama Wazni and Petr Stadler Abstract | Robotic technology has been used in cardiovascular medicine since the late 1990s. Interventional cardiology, electrophysiology, endovascular surgery, minimally invasive cardiac surgery, and laparoscopic vascular surgery are all fields of application. Robotic devices enable endoscopic reconstructive surgery in narrow spaces and fast, very precise placement of catheters and devices in catheter-based interventions. In all robotic systems, the operator manipulates the robotic arms from a control station or console. In the field of cardiac surgery, mitral valve repair, CABG surgery, atrial septal defect repair, and myxoma resection can be achieved using robotic technology. Furthermore, vascular surgeons can perform a variety of robotically assisted operations to treat aortic, visceral, and peripheral artery disease. In electrophysiology, ablation procedures for atrial fibrillation can be carried out with robotic support. In the past few years, robotically assisted percutaneous coronary intervention and abdominal aortic endovascular surgery techniques have been developed. The basic feasibility and safety of robotic approaches in cardiovascular medicine has been demonstrated, but learning curves and the high costs associated with this technology have limited its widespread use. Nonetheless, increased procedural speed, accuracy, and reduced exposure to radiation and contrast agent in robotically assisted catheter-based interventions, as well as reduced surgical trauma and shortened patient recovery times after robotic cardiovascular surgery are promising achievements in the field. Bonatti, J. et al. Nat. Rev. Cardiol. 11, 266–275 (2014); published online 25 March 2014; doi:10.1038/nrcardio.2014.23
Introduction Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Sowwah Square, PO Box 112412, Abu Dhabi, United Arab Emirates (J.B.). Pauley Heart Center, Virginia Commonwealth University, Medical College of Virginia, Box 980036, Cardiology Division Room 607 West Hospital, Richmond, VA 23298‑0036, USA (G.V.). Regional Vascular Unit, Division of Surgery, St Mary’s Hospital, Imperial College London, Room 1003, 10th Floor, QEQM Building, Praed Street, London W2 1NY, UK (C.R.). Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA (O.W.). Department of Vascular Surgery, Na Homolce Hospital, Roentgenova 2, 15030 Prague 5, Czech Republic (P.S.). Correspondence to: J.B. bonattj@cleveland clinicabudhabi.ae
Robotic technology is integral to mass production in industry. The main advantages of the use of robotic technology are the increased levels of speed, precision, reproducibility, and endurance of these machines com‑ pared with human performance. In medicine, robotic technology has been used since the mid‑1990s, primar‑ ily in the fields of surgery and radiation therapy. Robotic technology offers ergonomic advantages for operators, providing a relaxed, comfortable operator experience with less orthopaedic stress than with conventional sur‑ gical techniques. In cardiovascular medicine, robotic systems are now routinely used for minimally inva‑ sive atrial septal defect closure, mitral valve repair, and CABG surgery. New robotic systems are under devel‑ opment for a number of other indications, such as per‑ cutaneous coronary intervention (PCI), endovascular and minimally invasive surgical aortic repair, as well as catheter-based ablation for atrial fibrillation. Although observational and nonrandomized comparative studies have demonstrated the basic feasibility and safety of robotics in cardiovascular medicine, as will be discussed below, cardiovascular surgeons and interventionists have been slow to accept this technology owing to the learning Competing interests G.V. is an investigator in the PECISE trial for Corindus Vascular Robotics. C.R. is a consultant for Hansen Medical, and has received educational fees from Gore Medical and Medtronic. The other authors declare no competing interests.
266 | MAY 2014 | VOLUME 11
curve and high costs associated with its use. Some roboti‑ cally assisted procedures are still in early development, and are performed at only a small number of centres worldwide. Prospective, randomized studies to compare robotic technology with standard approaches have not been performed to date. In this Review, we outline the main fields of appli‑ cation of robotic technology in cardiovascular medi‑ cine and describe the robotic systems currently in use (Table 1). Also discussed are the advantages, disadvan‑ tages, and future directions related to the use of robotic technology in cardiovascular medicine.
Interventional cardiology The aim of using robotic technology in interventional cardiology is to precisely steer and position guidewires and balloons or stents for catheter-based coronary inter‑ ventions, thereby shortening procedure time and redu cing patient exposure to contrast agent and radiation. An interventional cardiologist controls these manoeuvres remotely from a console behind a radiation shield. The increased distance from the X‑ray equipment can also reduce radiation exposure for operators. Use of a robotic system enables the operator to make very precise measurements of lesion length, which could potentially reduce the number of stents used per lesion (a cost advan‑ tage) and the incidence of longitudinal geographic miss, in which the stent is misplaced (reducing the incidence of late recurrent events).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
REVIEWS Key points ■■ The main fields of use of robotic technology in cardiovascular medicine are endoscopic cardiac and vascular surgery, endovascular surgery, catheter-based ablation therapy for atrial fibrillation, and percutaneous coronary intervention ■■ Robotic devices enable complex endoscopic reconstructive manoeuvres in narrow spaces and can increase surgical precision; however, robotically assisted totally endoscopic approaches in cardiac and vascular surgery are technically challenging ■■ In catheter-based interventions, robotic technology leads to improved catheter stability and reduced radiation exposure to both intervention teams and patients ■■ All robotically assisted cardiovascular surgical procedures and catheter-based interventions involve a learning curve, during which conversion rates to conventional techniques and operative times are reduced ■■ Prospective, randomized trials to compare robotic and conventional approaches are lacking; observational studies and nonrandomized comparative studies show basic feasibility and safety of robotic interventions and intermediate-term results are promising
Robotic systems The CorPath® 200 (Corindus Inc., USA) system was introduced clinically in 2010, and the results of the first clinical studies of PCI using this robotic system are avail‑ able.1,2 The CorPath® 200 is the only system currently available for this indication and was approved by the FDA in 2012. The bedside unit comprises an articulated robotic arm that contains a robotic drive and a single-use cassette. An interventional cardiologist manipulates the guidewire, balloon, and stent catheters with one hand, and has the option of controlling the contrast-media injector with the other hand. The operator can follow fluoroscopic imaging, electrocardiography, and haemodynamic moni‑ toring from the cockpit. The control console and robotic arm are connected via a communication cable. Results The first report of robotically assisted interventional cardiology procedures in humans was published in 2011 and involved coronary angioplasty in eight patients.1 These individuals had single coronary artery stenoses with a mean lesion length of 11 mm in target vessels 2.5–4.0 mm in diameter. The mean procedure time was 43 min with a mean fluoroscopy time of 11.5 min. The primary end point of the study was clinical success of the device (defined as
Introduction Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Sowwah Square, PO Box 112412, Abu Dhabi, United Arab Emirates (J.B.). Pauley Heart Center, Virginia Commonwealth University, Medical College of Virginia, Box 980036, Cardiology Division Room 607 West Hospital, Richmond, VA 23298‑0036, USA (G.V.). Regional Vascular Unit, Division of Surgery, St Mary’s Hospital, Imperial College London, Room 1003, 10th Floor, QEQM Building, Praed Street, London W2 1NY, UK (C.R.). Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA (O.W.). Department of Vascular Surgery, Na Homolce Hospital, Roentgenova 2, 15030 Prague 5, Czech Republic (P.S.). Correspondence to: J.B. bonattj@cleveland clinicabudhabi.ae
Robotic technology is integral to mass production in industry. The main advantages of the use of robotic technology are the increased levels of speed, precision, reproducibility, and endurance of these machines com‑ pared with human performance. In medicine, robotic technology has been used since the mid‑1990s, primar‑ ily in the fields of surgery and radiation therapy. Robotic technology offers ergonomic advantages for operators, providing a relaxed, comfortable operator experience with less orthopaedic stress than with conventional sur‑ gical techniques. In cardiovascular medicine, robotic systems are now routinely used for minimally inva‑ sive atrial septal defect closure, mitral valve repair, and CABG surgery. New robotic systems are under devel‑ opment for a number of other indications, such as per‑ cutaneous coronary intervention (PCI), endovascular and minimally invasive surgical aortic repair, as well as catheter-based ablation for atrial fibrillation. Although observational and nonrandomized comparative studies have demonstrated the basic feasibility and safety of robotics in cardiovascular medicine, as will be discussed below, cardiovascular surgeons and interventionists have been slow to accept this technology owing to the learning Competing interests G.V. is an investigator in the PECISE trial for Corindus Vascular Robotics. C.R. is a consultant for Hansen Medical, and has received educational fees from Gore Medical and Medtronic. The other authors declare no competing interests.
266 | MAY 2014 | VOLUME 11
curve and high costs associated with its use. Some roboti‑ cally assisted procedures are still in early development, and are performed at only a small number of centres worldwide. Prospective, randomized studies to compare robotic technology with standard approaches have not been performed to date. In this Review, we outline the main fields of appli‑ cation of robotic technology in cardiovascular medi‑ cine and describe the robotic systems currently in use (Table 1). Also discussed are the advantages, disadvan‑ tages, and future directions related to the use of robotic technology in cardiovascular medicine.
Interventional cardiology The aim of using robotic technology in interventional cardiology is to precisely steer and position guidewires and balloons or stents for catheter-based coronary inter‑ ventions, thereby shortening procedure time and redu cing patient exposure to contrast agent and radiation. An interventional cardiologist controls these manoeuvres remotely from a console behind a radiation shield. The increased distance from the X‑ray equipment can also reduce radiation exposure for operators. Use of a robotic system enables the operator to make very precise measurements of lesion length, which could potentially reduce the number of stents used per lesion (a cost advan‑ tage) and the incidence of longitudinal geographic miss, in which the stent is misplaced (reducing the incidence of late recurrent events).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
REVIEWS Key points ■■ The main fields of use of robotic technology in cardiovascular medicine are endoscopic cardiac and vascular surgery, endovascular surgery, catheter-based ablation therapy for atrial fibrillation, and percutaneous coronary intervention ■■ Robotic devices enable complex endoscopic reconstructive manoeuvres in narrow spaces and can increase surgical precision; however, robotically assisted totally endoscopic approaches in cardiac and vascular surgery are technically challenging ■■ In catheter-based interventions, robotic technology leads to improved catheter stability and reduced radiation exposure to both intervention teams and patients ■■ All robotically assisted cardiovascular surgical procedures and catheter-based interventions involve a learning curve, during which conversion rates to conventional techniques and operative times are reduced ■■ Prospective, randomized trials to compare robotic and conventional approaches are lacking; observational studies and nonrandomized comparative studies show basic feasibility and safety of robotic interventions and intermediate-term results are promising
Robotic systems The CorPath® 200 (Corindus Inc., USA) system was introduced clinically in 2010, and the results of the first clinical studies of PCI using this robotic system are avail‑ able.1,2 The CorPath® 200 is the only system currently available for this indication and was approved by the FDA in 2012. The bedside unit comprises an articulated robotic arm that contains a robotic drive and a single-use cassette. An interventional cardiologist manipulates the guidewire, balloon, and stent catheters with one hand, and has the option of controlling the contrast-media injector with the other hand. The operator can follow fluoroscopic imaging, electrocardiography, and haemodynamic moni‑ toring from the cockpit. The control console and robotic arm are connected via a communication cable. Results The first report of robotically assisted interventional cardiology procedures in humans was published in 2011 and involved coronary angioplasty in eight patients.1 These individuals had single coronary artery stenoses with a mean lesion length of 11 mm in target vessels 2.5–4.0 mm in diameter. The mean procedure time was 43 min with a mean fluoroscopy time of 11.5 min. The primary end point of the study was clinical success of the device (defined as
