1. Robotics in the Cath Lab
Ryan D Madder, MD, FACC
Section Chief, Interventional Cardiology
Medical Director, Cardiac Cath Lab
Frederik Meijer Heart & Vascular Institute
Spectrum Health
&
Clinical Associate Professor of Medicine
Michigan State University
College of Human Medicine
Grand Rapids, Michigan

2. Disclosures
I receive research support from Corindus Vascular Robotics.

3. Occupational Hazard #1: Wearing Lead Apparel
Results of the 2014 SCAI Survey of Interventional Cardiologists
(%)
By multivariable analysis, annual case load was independently associated with risk of orthopedic injury
Any Ortho Injury
Hip/Knee/Ankle
Cervical Spine
Lumbar Spine
Klein et al. Catheter Cardiovasc Interv 2015;86:

4. Work-related Pain in the Cardiac Cath Lab
Technologists
Nurses
Orme et al. J Am Coll Cardiol 2015;65:820–6

5. Occupational Hazard #2: Chronic Radiation Exposure
Interventional cardiologists are at increased risk for:
Premature cataracts
Carotid atherosclerosis and early vascular aging
Left-sided brain malignancies
Higher levels of somatic DNA damage
Catheter Cardiovasc Interv 2010;76:
J Am Coll Cardiol Intv 2015;8:616-27
Am J Cardiol 2013;111:
Andreassi et al. FASEB J 2005;19:

6. Cardiac catheterization: Has the process really changed?

7. Robotic PCI: A novel approach to reduce operator radiation exposure
Cockpit
Bedside Robotic Arm

8. An Overview of the Robotic Controls
Wire Control
Forward/back
&
Torque
Balloon/Stent Control
Forward/back
Turbo Button
Touch Screen Controls

9. Next Generation of Robotic PCI: Guide Catheter Control
Wire
control
Guide-catheter control
Balloon/stent control

10. Robotic PCI: Unique Features
Protection – Enables the physician to move away from the radiation source, eliminating the need to wear lead
Precision – Device movements controlled to 1-mm increments
Measurement – Sub-mm measurement of lesion length
Visualization – Monitors are positioned in optimal view

11. Clinical Data for Robotic PCI: The PRECISE Study
Prospective observational design
20 physicians
9 sites
164 patients underwent attempted robotic PCI
No device related complications
Weisz et al. J Am Coll Cardiol 2013;61:

12. Success Rates for Robotic PCI: The PRECISE Study
Primary endpoints:
Technical success - successful advancement/retraction of all PCI devices without conversion to manual
Procedural success - residual stenosis <30% at completion of procedure in absence of MACE at 48 hours or prior to hospital discharge (whichever came first)
(%)
Weisz et al. J Am Coll Cardiol 2013;61:

13. Physician radiation exposure in the PRECISE study
Median Radiation Exposure per Case
Robotics:
95.2% Radiation
At the Table
In the Cockpit p
20.6 μGy
0.98 μGy
<0.0001
Weisz et al. J Am Coll Cardiol 2013;61:
Operator A: Manual
Operator B: Robotics
(20.6 μGy per PCI) x (100 PCI per year)
Annual Exposure
2,060 μGy per year
(0.98 μGy per PCI) x (100 PCI per year)
Annual Exposure
98 μGy per year
Over First 20 Years of Career
41,200 μGy
Over First 20 Years of Career
1,960 μGy

14. Impact of Robotic PCI on Physician Radiation During PCI
14.9
Compared to manual PCI, robotic PCI was associated with
99.3%
less cranial radiation
p<0.001
Cranial radiation per case (μSv)
0.1
Madder et al.
Cardiovasc Revasc Med 2016
Epub ahead of print
N=123
N=45

15. No Evidence that Robotic PCI Increases Radiation Usage
Manual PCI
N = 123
Robotic PCI
N = 45
P-value
Fluoroscopy time (min)
11.9 [10.8]
11.7 [6.8]
0.81
Air kerma (mGy)
1375 [1244]
1272 [1068]
0.67
DAP
(mGy x cm2)
94609 [86978]
99347 [93170]
0.91
Madder et al. Cardiovasc Revasc Med 2016 Epub ahead of print

16. Where is Robotic PCI Going? Future Directions

17. Telestenting: Introduction of a Novel Concept
The performance of PCI, using a combination of robotics and telecommunications, by an operator who is in a separate physical location than the patient
Physician in Location “A”
Patient in Location “B”
Remote PCI

18. Is Telestenting Even Feasible? The REMOTE-PCI Study
Madder et al EuroIntervention 2017;12:

19. Successful Robotic PCI Program
Keys to Developing a
Successful Robotic PCI Program
Commitment: Similar to adopting radial access, developing proficiency with robotic PCIs requires a commitment to consistent practice
Approach: approach all cases as suitable for robotic intervention
Conversion to manual should not be considered failure
Use robotic PCI as a means to re-introduce radiation safety in your cath lab