50697069 - view of modern medical x-ray operating room (cath lab).

As physicians, we are constantly searching for ways to improve patient care, by implementing new technology and by identifying new and better ways to perform procedures. As an interventional cardiologist, this search led me to take on chronic total occlusions (CTOs), a space once thought to be too complex for the cath lab.

For decades, patients with this diagnosis did not receive revascularization for a variety of reasons, including low success rates, higher complication rates, and lengthy procedures. We overcame these barriers by training physicians and cath lab teams to adopt a programmatic approach to treatment—one that leveraged algorithmic decision making to improve success rates and increase confidence with the procedure.

 

The need for robotics in the cath lab

In my new role as the Chief Medical Officer of Corindus Vascular Robotics, I’m taking on another paradigm-shifting technology in the cath lab—robotic therapy. At present, interventionalists and their staff are at significant risk due to the occupational hazards of working with radiation exposure. In fact, interventional cardiologists receive the highest amount of radiation exposure of any medical professional1. Among the risks,

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  • Left-sided brain tumors. When performing fluoroscopy-guided invasive cardiovascular procedures, interventional cardiologists receive 4.7 times more radiation exposure on the left side of the head compared to the right2; and an ongoing registry shows that 86% of brain tumors amongst interventionalists occur on the left side of the brain3.
  • Cataracts.4 Mounting evidence shows a link to a series of significant stochastic health effects such as posterior subcapsular lens changes (a precursor to cataracts). In the RELID study, 50% of interventional cardiologists had posterior subcapsular lens changes vs. <10% in the control group. Interventionalists with lens opacities had an estimated cumulative radiation dose to the eye that was 2.8 times higher than those without lens opacities.
  • Orthopedic injuries.5 There is a risk that using the standard lead-based personal protective equipment—such as lead aprons, vests, and collars that can altogether weigh up to 40 lbs.—can cause debilitating spinal and other severe musculoskeletal and orthopedic conditions to the back, neck, hips, ankles, and knees. Data shows that 60% of interventionalists practicing over 21 years have orthopedic injuries. I personally have already undergone one back surgery.

An increase in research on the risks has given rise to increased awareness and advocacy for new methods of protection. Cardiovascular robotics have shown significant benefit in this regard. Studies have shown a 95% reduction in radiation exposure for physicians6, preliminary data shows potential for reduction in staff exposure7, and a culture of radiation safety is being built in hospitals that have adopted robotic programs. That said, I believe there is tremendous potential for this technology to go beyond protection to fundamentally improve how procedures are done.

 

Implementation requires a program-based approach

We know robotics can improve safety and potentially patient care. But in order to do so, hospitals must adopt a program-based approach. There are many parallels that can be drawn between the implementation of a CTO program and a robotic program. While the specific barriers are not the same as CTOs, the ability to identify roadblocks, apply established key learnings, and work towards solutions will be critical to adoption.

The next step is to leverage the experiences of these hospitals to advance the technology. As procedures increase in complexity, integration of multiple technologies and techniques into a robotic platform will increase efficiency and maximize the benefits for both patients and operators. Investing in capability and functionality updates that will create the greatest change is essential to making a significant difference in this regard.

My involvement is based not on what the technology offers now, but where I believe cardiovascular robotics can go and what it can do for interventional cardiology. Robotic therapy is on the cusp of achieving its potential and with the help of forward-thinking physicians who seek to get involved, we can drive the technology and the specialty forward.


References:
1. E. Picano, et al., “Occupational Risks of Chronic Low Dose Radiation Exposure in Cardiac Catheterisation Laboratory: The Italian Healthy Cath Lab Study.” European Medical Journal International, 50-58 (2013).
2. Reeves, R.R., Ang, L., Bahadorani, J., Naghi, J., et al. “Invasive cardiologists are exposed to greater left side cranial radiation: The BRAIN study (Brain radiation exposure and attenuation during invasive cardiology procedures).” JACC Cardiovasc Interv. 2015; 8:1197-206.
3. Roguin, A. “Radiation hazards to interventional cardiologists: A report on increased brain tumors among physicians working in the cath lab.” SOLACI 2014; April 23, 2014; Buenos Aires, Argentina.
4. Vano, E., Kleiman, N.J., Duran, A., Romano-Miller, M., Rehani, M.M. “Radiation-associated lens opacities in catheterization personnel: Results of a survey and direct assessments.” J Vasc Interv Radiol. 2013; 24:197-204.
5. Klein, L.W., Tra, Y., Garratt, K.N., Powell, W., et al. “Occupational health hazards of interventional cardiologists in the current decade: Results of the 2014 SCAI membership survey.” Catheter Cardiovasc Interv. 2015.
6. Weisz, G. et al. “Safety and Feasibility of Robotic Percutaneous Coronary Intervention: PRECISE Study.” J Am Coll Cardiol. 2013;61(15):1596-1600. PRECISE Trial demonstrated 95.2% reduction in radiation exposure to the primary operator.
7. Campbell, P., et al. “Staff Exposure to X-ray during PCI: Randomized Comparison of Robotic vs Manual Procedures.” Presented at SCAI 2016.

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J. Aaron Grantham, MD
J. Aaron Grantham, MD is with Saint Luke’s Mid America Heart Institute, a member of Saint Luke’s Health System, as Associate Professor, University of Missouri-Kansas City School of Medicine. He is Director of the school’s Cardiovascular Disease Fellowship Program and Director of Cardiovascular Medical Education at Saint Luke’s Hospital. As a leading interventional cardiologist and an innovator in the treatment of chronic total occlusions, Dr. Grantham recently joined Corindus Vascular Robotics as Chief Medical Officer to educate the interventional cardiology community on the benefits of robotic therapy.

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