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“In the majority of robotic-assisted cases I perform, automated movements are particularly helpful in delivering gear – I can easily get balloons and stents around the C-shaped curve in the right coronary artery from the cockpit just like I would be able to if I were at the table. In addition to ensuring precision, this means that I’m offered a level of protection from the radiation exposure that interventional cardiologists typically experience. Robotics is one of the many components that can contribute to a radiation safety-based culture, which is a key area of focus for many teams in the interventional space to create safe working conditions and encourage strong teamwork and longevity.”

Rhian E. Davies is an interventional cardiologist.

She shares her story and discusses her KevinMD article, “Robotics, automation, and the future of remote health care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show we have Rhian Davies. She is an interventional cardiologist. Her KevinMD article is titled “Robotics, automation, and the future of remote health care.” Rhian, welcome to the show.

Rhian E. Davies: Thank you so much for having me.

Kevin Pho: We’ll get into the article in a little bit. First off, share your story and journey to where you are today.

Rhian E. Davies: OK, so I grew up in a small town in Pennsylvania. I elected to go on to get a lot more years of education. I went to medical school in Philadelphia and then did some six years of training in general internal medicine and general cardiology at Penn State Hershey. I went up to Brown University, where I specialized in interventional cardiology, and then out to the University of Washington with Dr. Lombardi, where I was able to learn robotic PCI. And then on my way back, more to the East Coast, here in York, Pennsylvania, at WellSpan Hospital.

Kevin Pho: All right, so walk us through a typical day of what you do as an interventional cardiologist, and talk about some of the common cases that you see.

Rhian E. Davies: Yeah, so that’s a great question. Within interventional cardiology, we see anything from straightforward normal coronaries, and we work patients up for chest pain, shortness of breath, those sorts of things. Sometimes, unfortunately, the chest pain is actually related to heart disease, and we find that they have blockages in their heart arteries. Some of those arteries are very straightforward to fix. Other ones are a little bit more complicated; they can be 100 percent blocked, and I have special training in opening those sorts of arteries. For a lot of patients who are maybe told that there’s no option for them, or that nothing can be done because it is very complicated to get them fixed up, we can actually offer that service at my institution.

Kevin Pho: All right, so I’m certainly interested in hearing more about that intersection between robotics and interventional cardiology, which you talk about more in your KevinMD article titled “Robotics, automation, and the future of remote health care.” Now, for those who didn’t get a chance to read that article, just walk my audience through it and share the story of why you decided to write it.

Rhian E. Davies: Yeah, so robotics. Before my year at the University of Washington, I didn’t really know how robotics fit into the PCI world. To me, I thought the doctor needed to be at the bedside in order to perform the procedures, but in reality, you can do a lot with the robotic PCI system.

So basically, this offers the opportunity for patients who live in rural or smaller communities to get the care that they would get at a well-recognized or very large hospital, because the robotics is able to be used on them, and the operator of the device can be miles, if not states, if not even a country away. It kind of just depends on the setup. Through automation, they’ve watched how certain physicians wire coronary arteries, deliver balloons, deliver stents, and image coronaries, and they were able to develop an automated system that basically we sit there and control with a few levers and stick shifts, basically advancing wires and advancing the guides, and we can fix everything from straightforward lesions to very complex lesions.

Kevin Pho: All right, so walk us through a typical case of a patient who would undergo robotic cardiac intervention. So the patient’s in the room. Who’s in the room with that patient? And let’s say the operator of that robot is miles away. What exactly would that look like?

Rhian E. Davies: So basically, you have a tech and/or nurse. You have a couple of people in the room at all times with the patient. They set the patient up, they get access, and they put in your guide of choice. Depending on what artery you’re fixing or what you’re doing, they’ll put that guide in, and then you can engage. Then everything kind of goes to the robotic system. So you engage the robot from your control booth, wherever that may be, and then you’ll ask for certain wires. You’ll be able to advance the wires into the coronaries. You have the ability to use what they call technIQ, or the automation system, which is a series of different wiring strategies. And then when it comes to delivering devices such as your balloons and eventually your stents, you can use additional automated systems to do that.

And then to image, we trust that the tech at the bedside is able to deliver the IVUS catheter, or the ultrasound machine, or the OCT machine, depending on what we’re using, to do a final assessment of the vessel. But it’s very much as if you were right there doing it, while having the ability to do it from miles away.

Kevin Pho: So tell us the type of coronary blockages, the type of patients, that is most suitable for a robotic approach.

Rhian E. Davies: Yeah, that’s a wonderful question. So this was originally developed when they were more straightforward, what we call type A lesions. Unfortunately, with the progression of coronary disease, we don’t get a whole lot of type A lesions, and certainly I don’t; I get more of the complex disease. That’s where this automation has really helped, and this was recently noted in a trial that Corindus, or Siemens, had done called NAVIGATE, where more complicated lesions were actually wired with the robot and then PCI performed. But they can be straightforward single-vessel to bifurcation fixing, meaning two or more vessels needing intervention.

Kevin Pho: And in terms of outcomes, how do they contrast with a more traditional approach?

Rhian E. Davies: Very favorable. It’s pretty much the exact same, if not a little better, because you have the ability to do precise stent placement when you’re doing this. So if it’s an artery that I’m working on, I’ll put my wire down, and I get my distal spot where I want to land my stent, and the proximal stent. And because of the way that the robot is set up, it’s very streamlined, and everything that we put into the device goes exactly where we want it to go. Whereas sometimes, if you’re at the bedside, there is a little bit of motion, just from human motion or breathing and those sorts of things, which is rather eliminated with a robot.

Kevin Pho: Any patients or cardiac situations that are not suitable for a robotic approach?

Rhian E. Davies: So there’s always going to be maybe some tortuosity and those sorts of things that can cause a little bit of hindrance, or troubleshooting that you might need to do. But again, this comes from doing a lot of these cases and getting more comfortable with it. There might be situations where you might think, “Oh, this might be better served at the bedside, or doing it the traditional style,” but the majority of complicated cases you can get through doing on the robot. That’s the advantage of using the automation and the technIQ system now, because they’ve done a lot of work, and they’re continuing to do work there, that allows you to deliver wires and devices in a very streamlined fashion.

Kevin Pho: So let’s say you’re doing a robotic procedure remotely, and something, God forbid, goes wrong. What happens next?

Rhian E. Davies: Yeah, that’s an excellent question, and that’s something that we’ve talked about quite a bit. That’s where having the ability to call somebody in who’s close to the facility, if not present at the facility at that time, who can kind of step in and help or facilitate a change of strategy and whatnot, comes in. But I think those are ongoing things that we’re talking about.

Kevin Pho: So how common is a robotic approach to cardiac intervention? Is it primarily available in certain parts of the country, and what’s the penetration of this technology?

Rhian E. Davies: Yeah, I think it’s growing on a regular basis. More and more hospitals are developing or adapting the robot into their cath lab. Certainly there’s been a huge increase in the neurovascular and peripheral space, and I think, as a result, the cardiac space is also starting to pick up. So it’s becoming more widely available throughout the U.S. and through the European countries.

Kevin Pho: So any other cardiac diseases other than coronary artery disease that we can use the robot for?

Rhian E. Davies: At the present moment, not with the robot that is currently developed, but I think that is a hope, that down the road, more of these procedures will be robotic in nature.

Kevin Pho: We’re talking to Rhian Davies. She’s an interventional cardiologist. Her KevinMD article is titled “Robotics, automation, and the future of remote health care.” So, Rhian, going forward in the next three to five years, I guess, look into your crystal ball. What do we have to look forward to when it comes to that intersection between interventional cardiology and technology?

Rhian E. Davies: I think this space is going to continue to grow. I think there are going to be more developments in it. I think artificial intelligence, AI technology, is exciting, and I think it is the way of the future. I think it’s just a matter of kind of stepping through all those little roadblocks that might come up at times, and just finding a way around them, such as, if something goes wrong, who’s going to be the backup person, that sort of stuff. But I think as the technology develops, more and more of those challenges are going to be decreased.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Rhian E. Davies: I think, number one, if you’re having symptoms, make sure you’re talking to a cardiologist and get evaluated. I’m certainly always happy to chat with patients and meet new patients. And I think it’s about being excited for the future and knowing the possibilities out there, and never stopping at “nothing can be done.” There are always options for you, and I think artificial intelligence is only going to help us make more options available in the future.

Kevin Pho: Thank you so much for sharing your time and insight. Thanks again for being on the show.

Rhian E. Davies: Thank you so much. I appreciate it.