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The Robotic Technology in Interventional Cardiology

The past few years have witnessed amazing advances in the robotic technology leading to its widespread utilization in both research and clinical aspects across multiple fields, including the cardiovascular field! I have recently attended a few conferences and the footprint of the robotic technology has been remarkable in each of them, emphasizing the great interest in the progress and utility of technology in our field. I decided to talk about robotic technology in interventional cardiology, the advantages and limitations of its use, and how I see it impacting the future of interventional cardiology.

  • How long have we used robotic technology in the cath lab?

Robotic technology has been used in surgical specialties and radiation therapy since the mid-1990s. Then, robotics systems for endovascular interventions were developed and have been utilized for different percutaneous interventions, including simple and complex coronary and peripheral interventions, as well as other structural heart disease procedures, including atrial septal defect closure.

  • Do we have scientific evidence-based trials assessing the robotic technology in interventional cardiology?

There are many prospective trials looking at robotic technology in both coronary and peripheral interventions. The two major studies are:

  1. PRECISE (Percutaneous Robotically Enhanced Coronary Interventions) trial: 164 patients with relatively simple lesions (>87% ACC/AHA type A/B; lesion length 12.2 6 4.8 mm), the investigators reported clinical success of 97.6%, technical success of 98.8% and > 95% median operator radiation reduction. Based on the results of this study, in 2012, the FDA approved the CorPath 200 System as the first robotic system for PCI.
  2. The RAPID (Robotic-Assisted Peripheral Interventions for Peripheral Artery Disease) trial, a prospective single-center, safety and feasibility study demonstrated the utility of the CorPath 200 system for robotic peripheral interventions. The study demonstrated 100% device technical and clinical success. No significant adverse events related to the device were reported, and based on this study, the CorPath 200 system received FDA approval for peripheral interventions.
  • Advantages
  • One of the main advantages of the robotic system in the cath lab is the reduction of radiation exposure for both the operators. The hazards of radiation are well-known and studies have demonstrated that the use of robots led to a reduction in radiation exposure [1]. Operators using the robotic system can either be in the cath lab several feet away from the radiation source or even in a separate room, where they can control the joystick and use the control pad to adjust the robot movements to control wires, the guide catheters and other devices (balloon, stents, etc..).
  • Robots also help avoid wearing heavy lead aprons and thus decrease the orthopedic problems that many operators suffer from in the long run, including back pain and arthritis.
  • Moreover, studies have also shown that robotic system use is associated with good precision and outcomes [1].
  • Robots have been increasingly utilized with around 100 hospitals in the US currently using robots in the cath lab. This quick and widespread utilization of this new technology demonstrates not only how safe and successful the robotic system is, but also how easy and user-friendly it is.

 

  • Limitations

In my opinion, this tool was developed to help operators, but not to replace them. Like any tool, the machine can potentially stop working, for a technical reason or other reasons, and at the end of the day, it is the physician’s responsibility to deal with the situation and solve the problem. In addition, the use of robotic system is limited in the following:

  • The use of robotics in STEMI or bifurcation lesions has not been well-established yet, although reports and smaller studies have shown it can be performed safely.
  • There are technical limitations of the robotic system, and if a lesion could not be treated, manual conversion is recommended.
  • Limited devices used by the current generation of robotic technology: use of over-the-wire balloons, intra-vascular imaging catheter, or mechanical circulatory support is not available with the current generation of robotics.
  • How will robots change the future of interventional cardiology?

The robotic technology has been increasingly utilized in multiple hospitals across the world. With more experience with robotic technology utilization, more knowledge and future upgrade of robotic systems, I think this tool will be increasingly utilized and updated to conform to the needs of patients, operators and different kinds of procedures and interventions; in fact, the robotic system is being studied in the utility of transcatheter aortic valve replacement (TAVR) procedures! Moreover, the utility of the robotic technology could potentially enable experienced operators to remotely perform complex interventional procedures in patients in different hospitals in rural or urban areas, different states, different countries or even different continents!

With the rapid progress in technology in all fields of our life, I think it is very important to establish and encourage more collaborations between technology and medical sciences, especially in procedural specialties, where precision and safety can be provided by these advanced robotics systems for optimal outcomes. I look forward to seeing how these technologies will evolve and transform our practice in the future!!

 

I would like to thank my colleague and friend, Dr. Jeff Hsu, for his help on this blog and for being an awesome senior buddy!!

References

  • Mahmud et al: Robotic technology in interventional cardiology: Current status and future perspectives. Catheter Cardiovasc Interv.2017 Nov 15;90(6):956-962.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.27209

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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The American Heart and Go Red for Women Month!

It is February: The American Heart and Go Red for Women Month!

February has just started with all its excitement and optimistic thoughts!! I would like to talk about some of the amazing initiatives, including American Heart Month and Go Red for Women initiatives, that are in place to inspire and encourage more of my colleagues, women and men equally, to step up and be proactive about women’s health and education!

  • When was the first American Heart Month?

It was in February 1964, proclaimed by President Lyndon B. Johnson, and Congress subsequently requested the President to issue a proclamation designating February as American Heart Month annually.

  • What is the Go Red for Women Initiative?

It is an initiative, launched in 2004, to end heart disease and stroke in women; by increasing awareness of these diseases in women and removing barriers women face to achieve a healthy life. Here is what GO RED means:

  • G: GET YOUR NUMBERS

Ask your doctor to check your blood pressure and cholesterol.

  • O: OWN YOUR LIFESTYLE

Stop smoking, lose weight, exercise, and eat healthy.

  • R: REALIZE YOUR RISK

Know your risk; heart disease is responsible for 1 in every 5 female deaths [1].

  • E: EDUCATE YOUR FAMILY

Make healthy food choices for you and your family.

  • D: DON’T BE SILENT

Tell every woman you know that heart disease is our No. 1 killer [1].

  • How about “Research Goes Red” initiative?

It is an initiative to increase women’s participation in scientific research. Both healthy women and those with acute or chronic diseases are encouraged to participate.

  • What impact have these initiatives achieved?

The impact of these initiatives has been remarkable and quite impressive!! Here are some of their achievements:

  • More than 25,000 women registered for the Research Goes Red initiative!
  • Around 19 million women interact with Go Red through digital platforms annually.
  • $600 million raised to support research, education, advocacy, prevention and awareness programs.

Seeing the impact of these initiatives, I am hopeful not only that these initiatives continue to include and support more women, but also I am optimistic that more initiatives are launched to: (1) increase awareness of different heart diseases in women, (2) empower women to know the differences in the clinical presentations of different diseases, (3) implement strategies to avoid health care disparities based on gender and race, and (4) help more women and minorities access health care, not only across the nation but also across the globe.

 

Reference

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock

Mechanical circulatory support (MCS) use in cardiogenic shock (CS) in the setting of acute myocardial infarction (AMI) is one of the most controversial topics in cardiology. Despite advances in many aspects in our cardiovascular field, mortality from CS remains unacceptably high. At the most recent AHA meeting, two studies suggested the use of intra-aortic balloon pumps (IABP) in CS might result in better outcomes compared to use of the percutaneous MCS device, Impella. I wanted to share my thoughts and ideas on this topic in light on these studies.

Major Randomized Clinical Trials on MCS

There is limited evidence in the literature supporting the use of MCS in AMI-CS1-3. There are two main randomized clinical trials in MCS devices: IABP-SHOCK II and IMPRESS trials. IABP-SHOCK II trial compared IABP with medical treatment in 600 patients with AMI-CS, and showed no difference in survival between the two groups2. The IMPRESS trial compared Impella CP versus IABP in 48 patients with CS-AMI and again did not show a difference in survival between these groups3.

Summary of recently-released studies at AHA19

A study by Amin et al, which included 48,306 patients undergoing percutaneous coronary intervention (PCI) with MCS from the Premier Healthcare Database, found wide variations in the use and clinical outcomes of Impella (mortality, stroke, bleeding, acute kidney injury) across hospitals. They also found that Impella had higher odds of adverse events and higher costs compared to IABP after adjusting for hospital, patients and time period4.

A separate study by Dhruva et al, which included 28,304 matched patients with AMI-CS undergoing PCI from NCDR Cath-PCI registry, found that 8,471 patients (29.9%) had IABP only, and 1,768 patients (6.2%) had Impella only. In-hospital outcomes were compared; in-hospital mortality was 34.1% with IABP compared to 45% with Impella use, and in-hospital bleeding rates were also lower in IABP group with 16% versus 31.3% in the Impella group5.

Discussion

In light of the results of these two observational real-world studies, I think we should take these results with a grain of salt. As we know, observational data has its own limitations, including confounding bias. Patients with AMI-CS may differ significantly based on their co-morbidity profile and angiographic complexity, which could potentially influence device selection; as we expect that patients who are sicker will usually get Impella as it provides more hemodynamic support compared to IABP, making comparison between these two devices inaccurate.

Both studies have shown an increase in the use of Impella over the past years, which is an opportunity to study these devices with larger numbers in different clinical settings. Registries across the nation are being established to build databases to compare these devices. Stronger evidence and more robust data with potential randomized clinical trials are much needed to help us know how to best manage this complex patient population and select which MCS device is optimal for each of our patient populations.

I would like to say special thank you to Dr Khaldia Khaled, my friend and colleague at Louisiana State University, for helping me write this blog and for her continued support.

 

References 

1- Schrage B et al: Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock. Circulation. 2019 Mar 5;139(10):1249-1258.

2- Thiele et al: Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock. N Engl J Med 2012; 367:1287-1296. DOI: 10.1056/NEJMoa1208410

3- Ouweneel DM et al: Experience from a randomized controlled trial with Impella 2.5 versus IABP in STEMI patients with cardiogenic pre-shock. Lessons learned from the IMPRESS in STEMI trial. Int J Cardiol. 2016 Jan 1;202:894-6. doi: 10.1016/j.ijcard.2015.10.063. Epub 2015 Oct 9.

4- Amin et al: The Evolving Landscape of Impella® Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention with Mechanical Circulatory Support.

Circulation. 2019 Nov 17. doi: 10.1161/CIRCULATIONAHA.119.044007.

5- https://www.tctmd.com/news/more-adverse-events-higher-costs-impella-new-observational-studies

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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My Experience at AHA19 Scientific Sessions

#AHA19 was an amazing meeting in all aspects!! I totally enjoyed every moment and definitely recommend all fellows and early career cardiologists to attend and participate in this important meeting. I will share my experience and highlight important sessions fellows and early career colleagues should not miss.

The fellow-in-training (FIT) and Early Career Lounge

The FIT/Early Career Lounge is always open and welcoming to all fellows. There were amazing sessions throughout the meeting guiding fellows in issues that matter to them at their current level of training or practice. There were great talks by experts in the field for those who were interested in scientific writing, pursuing a career in interventional cardiology, electrophysiology, heart failure, imaging…etc These sessions were packed with fellows and early career colleagues from all over the world. After each session, there were productive discussions between the audience and the speakers, that helped further make it extremely useful sessions to attend.

The Go Red Women in Science and Medicine Lounge

The Go Red Women in Science and Medicine Lounge was also packed by great talks and tips by amazing women leaders in the field. Topics ranged from time/priority management, collaborations between scientists and MDs in clinical practice, and how to advocate for women in our exciting cardiovascular field. Similarly, each session was followed by extremely helpful tips and discussions that is very relevant to all of us, regardless of our level of training or career level.

The AHA Presidential Session

The AHA Presidential session was one of a kind! Dr Robert Harrington shared his inspiring journey how he became involved in AHA and scientific research, emphasizing why evidence matters and how we all can contribute to this amazing cardiovascular field. We were all very excited and delighted by the Hamilton performance as well!!

Late Breaking Trials

Needless to say, the late and non-late breaking trials at #AHA19 were very relevant to our clinical practice, from ISCHEMIA, ISCHEMIA-CKD, GALILEO, COLCOT, RECOVERY, DAPA-HF and many other trials. These results were released in packed halls with standing attendees, showing the importance of these trials to our daily practice.

Technology/Simulation Hall and Poster Sessions

Moreover, there were concurrent sessions throughout the meeting for those of us who like to practice and use their hand skills in the technology and simulation hall, where you get to use the most up-to-date tools and equipment, including wires and simulation devices. In addition, the poster sessions were a great opportunity to engage in basic and clinical science and exchange ideas with researchers across the globe.

In conclusion, AHA19 was a great meeting that combined both basic and clinical sciences with emphasis on one goal: Evidence Matters for Better Patient Care. I look forward to AHA20 in Dallas, Texas on November 14-16!!

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.