Do we need robotics for coronary intervention more than ever in the COVID‐19 era?

To the Editor,

Over the last several months, cardiac catheterization laboratories (cath labs) around the world have had to adapt to the new challenges posed by the coronavirus disease 2019 (COVID‐19) pandemic. Although most elective cases are being canceled in an attempt to reduce the risk of exposure to both the patient and the healthcare provider, the need to perform urgent and emergent procedures, albeit prior to objective COVID‐19 rule out, continues to pose an ongoing risk. In an attempt to mitigate these unprecedented challenges, most providers have become more focused on the use of preprocedural personal protective equipment (PPE) and more stringent patient triage. Moreover, the global shortage and procurement of PPE have added to the strain in throughput. Not surprisingly, a recently published single‐center study from Hong Kong found significant delays in door‐to‐balloon and cath lab arrival‐to‐device time among patients presenting with ST‐elevation myocardial infarction (STEMI). ¹

Although social media has played an important role in sharing physician practices across the globe, standardization of management in these complex patients is lacking. For example, several Chinese centers use fibrinolytic therapy as the preferred first‐line therapy in the management of stable patients with STEMI, even at primary percutaneous coronary intervention (PCI) centers. Although not standard of care, this practice was implemented in order to minimize infection risk to healthcare providers. More recently, a joint statement from the American College of Cardiology (ACC) Interventional Council and the Society of Cardiovascular Angiography and Intervention (SCAI) provided cath lab‐specific considerations in the context of the COVID‐19 pandemic. ² Out of the many practical recommendations, a dedicated section dealt specifically with the appropriate use of PPE.

Despite monumental advances in the field of interventional cardiology, occupational hazard remains a major issue. The novel challenges specific to the management of patients with COVID‐19, however, require considerably more than the usual radiation. Widespread epidemics such as COVID‐19, Middle East respiratory syndrome, and severe acute respiratory syndrome warrant further improvement in approach to PCI that can mitigate this occupational hazard. Robotic‐assisted PCI (R‐PCI) holds potential to tackle such an issue. R‐PCI has been approved for coronary interventions and has had increasing adoption in elective and complex procedures globally.3, 4 After obtaining vascular access and engaging the coronary artery, the operator can stay 6 ft (2 m) away from the patient as recommended by the Center of Disease Control (CDC). Furthermore, the scrubbed technician at the table can remain at the end of the table sufficiently distant from the patient. Alternatively, the scrubbed operator, as a single person, can rotate between the tableside and cockpit positions to perform the entire procedure while maintaining distancing from patient and minimizing the exposure risk to other personnel. Safety of R‐PCI was evaluated in the PRECISE (Percutaneous Robotically Enhanced Coronary Intervention) trial in which procedural success was seen in 162 out of 164 patients. ³ For complex cases, the CORA‐PCI (Complex Robotically Assisted Percutaneous Coronary Intervention) study showed noninferiority when compared with manual PCI. ⁴ Additional benefits of R‐PCI include reduction in radiation doses, more accurate assessment of lesion length, and precise deployment of coronary balloons and stents. Finally, the implementation of remote PCI, which has been successfully demonstrated in nonemergent patient settings with the operator in a geographically distant location outside of the procedural hospital, ⁵ would allow further reduction of exposure to personnel in these pandemic environments.

Thus, in our opinion, R‐PCI can provide an additional layer of protection to the healthcare personnel involved in the management of patients at high risk for COVID‐19 or confirmed positives that require urgent or emergent coronary intervention. This may be especially useful in situations where access to PPE is limited, as in the current crisis. Future studies are needed to evaluate the utility of R‐PCI in the management of STEMI, especially in pandemic environments. Further innovation of this novel technology may result in broader adoption of R‐PCI among the interventional cardiology community.