Within the scope of modern medicine, highly complex medical technology has long since become inevitable, be it in the fields of intensive care, neurology or oncology. Cardiology and cardiac surgery are no exceptions. The spectrum of high-tech products that are used here range from balloon catheters to coated and biologically degradable coronary stents, all the way to synthetic cardiac valves and also special robotic systems. Therefore, it is an absolutely logical consequence that such innovative procedures and high-tech products will also become the focus of discussion at the world’s largest medical trade fair, the MEDICA in Düsseldorf, and the accompanying MEDICA EDUCATION CONFERENCE (12 to 15 November 2014).
Catheter-based heart valve procedures have received a lot of attention in the field of cardiology, especial in the case of patients with aortic stenosis. Here, the minimally invasive procedure (TAVI: transcatheter aortic valve implantation) has long since proven to be a good option for high-risk patients. In the case of conventionally inoperable patients, TAVI has already become the method of choice. And since there is a great deal of work being done on new implants, experience with the procedure is increasing and, in all likelihood, in the coming years, there will also be a lot of progress made regarding diagnostic evaluation (“Nature Reviews Cardiology” 2014; 11: 157–167; doi:10.1038/nrcardio.2013.221.). There is discussion going on, for example, concerning the benefit to younger patients and those with heart disease deemed to be at moderate or very low risk in the event of an operation. It is also currently being discussed if catheter-based procedures could be an appropriate alternative to convention operation after failure of an organic prosthesis.
To boot, there are catheter-based procedures on the mitral valve that are overshadowed by TAVI. Among other things, the complex anatomy of the mitral valve is a reason for this. In addition, as opposed to TAVI, the data situation for catheter-based procedures in the case of mitral regurgitation is not so elaborate. In the case of patients suffering from symptoms and who have operable severe mitral valve insufficiency, the surgical reconstruction is furthermore “the measure of all things” (“Der Kardiologe“ 2013; 7: 76 - 90). Admittedly, every second or third patient with severe symptomatic mitral regurgitation is not operated on, for example, due to impaired left ventricular function, relevant concomitant diseases and due to advanced age in particular. Consequently, there are hardly any therapeutic options for a relatively large number of patients suffering from mitral valve insufficiency.
The issue surrounding many current studies also includes new stents with biodegradable polymers, polymer-free stents as well as completely bioresorbable stents. According to the private lecturer, Thomas Pilgrim, and Professor Stephan Windecker from the University Hospital of Bern, here, there are already “very promising results in smaller studies” (“Der Kardiologe” 2014; 8: 168 - 178; doi: 10.1007/s12181-013-0537-9).
Robots: not a replacement for surgeons, but technology for mankind
Robots manufacture cars, play football, in the meantime, even speak out and write messages. In this respect, it is no wonder that in recent years, robotics and mechatronics have become established within many fields of medicine, above all in surgical disciplines. In this connection, it is not the objective to replace surgeons, but devise other options for therapy. Benefits of robotically assisted procedures include the following, irrespective of the field of application:
• speed and therefore saving time,
• precision and endurance,
• exact repeatability,
• no or a low level of radiation exposure to patients and treatment teams,
• ergonomic advantages to the surgeon.
The main criticisms include costs, the learning curve and the lack of tactile feedback for the surgeon. Scientists and engineers at the German Aerospace Centre (DLR) are therefore developing a new system that is based on a new unidirectional ultrasound sensor that makes it possible for surgeons to receive tactile feedback, even with regard to minimally invasive procedures - in this case, arteries.
Furthermore, the lack of prospective controlled studies in comparing robotically supported surgery with conventional operating procedures is considered a shortcoming in the fields of cardiology and cardiovascular surgery. In cardiovascular surgery, robots are used, for example, for the closure of an atrial septum defect, for bypass implants and for mitral valve operations. Furthermore, several new robotic systems have been developed for a variety of other indications including percutaneous coronary interventions, catheter-based ablations in the case of atrial fibrillations, and minimally invasive operations on the aorta. Examples of robotic systems that are used and can be used in cardiovascular medicine include:
• The “CorPath200-System” by Corindus Vascular Robotics for coronary angioplasty. This robotics system has been the only system for percutaneous coronary interventions that has been approved by the US authority, the FDA.
• The “Hansen Medical Sensei System” by Hansen Medical - specifically developed for electrophysiological operations, such as ablations in the case of atrial fibrillations.
• The “Magellan Robotic System” for operations on the peripheral arteries (in the case of an aortic aneurysm for example) and
• the “da Vinci Robotic System” for operations on the mitral valve, bypass operations, atrial and ventricle septal defects, atrial myxomas as well as for visceral surgery on the arteries for example.
A small point of view
According to an assessment by the heart surgeon, Professor Johannes Bonatti (Cleveland Clinic Abu Dhabi), who has dealt with robotically assisted operations for years, such procedures in the field of cardiovascular medicine will however be limited to specialised centres and teams in the coming years. However, from Bonatti’s point of view, this is also wise to keep the enormous costs for the systems under control (“Nature Reviews Cardiology” 2014; 11: 266–275; doi: 10.1038/nrcardio.2014.23).
For example, at the MEDICA 2014, catheter-based operations for valvular heart diseases and coronary stents are topics at the accompanying MEDICA EDUCATION CONFERENCE. Furthermore, here it has to do with the use of robotic systems, namely in the field of oncosurgery. From this year on, the German Society for Internal Medicine (DGIM) will be responsible for the subject content at the MEDICA EDUCATION CONFERENCE.
The group of topics “Telemedicine and Robotics” constitutes the primary focus at the MEDICA EDUCATION CONFERENCE (in the Congress Center Düsseldorf) to be held on Thursday, 13 November, 2014. This includes the plenary informational event, “Modern Surgery Robotics using the DLR Micro System by Way of Example”, the cardiology seminar, “Coronary Heart Disease – Always Just Catheters” or also the oncology discussion forum, “Robotics in Tumour Surgery”.
Information on the MEDICA 2014, the programme and other accompanying conferences, forums as well as exhibitors’ product highlights are online: http://www.medica-tradefair.com.
Author: Dr. Thomas Kron, freelance medical journalist (from Worms, Germany)