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In 2018, five patients at the Apex Heart Institute in Ahmedabad, India, underwent treatment for coronary artery disease (CAD), a method similar to that used by 3 million others each year: inserting a small balloon into the artery of the heart and inflating it, followed by placing a stent to keep the vital blood vessel open.

This process is known as percutaneous coronary intervention (PCI), the standard treatment for atherosclerosis, a common form of coronary heart disease characterized by the buildup of plaque within the arteries, which subsequently leads to restricted blood flow. Like many patients before them, their surgery was assisted by the CorPath GRX robotic platform from Siemens Healthineers.

However, unlike anyone before them, these five patients experienced a remarkable first: their attending physician was not in their room during the procedure. In fact, he was 20 miles away, guiding the robot to perform the operation perfectly from a remote workstation.

Welcome to the new frontiers of telemedicine.

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Robotic surgery addresses leading causes of death

According to the World Health Organization (WHO), cardiovascular diseases (CVD) are the leading cause of death globally, claiming 17.79 million lives each year. This impact is most severe in areas lacking readily available emergency care, such as developing countries and rural regions.

The WHO notes that over three-quarters of cardiovascular disease deaths occur in low- and middle-income countries. In developed nations, the issue arises in rural areas, where small hospitals often lack specialists in interventional cardiology. It is in these regions that remote solutions pioneered by Corindus and similar telemedicine options offer patients infinite hope and attractive possibilities.

Dr. Tejas Patel performed these remote interventions and, along with his colleagues Sanjay Shah and Samir Pancholy, published an article about these interventions in EClinicalMedicine. The article states, “The vast majority of patients with coronary heart disease or acute coronary syndrome in developing countries have little or no opportunity to receive timely interventional treatment. Currently, robotic technology, supported by improved network connectivity and operator expertise in R-PCI (robot-assisted PCI), can serve as a frontline service in areas lacking such specialized skills.” The article also notes that the system can serve as a supplementary service, providing specialized treatment to more patients.

New Frontiers in Telemedicine: Long-Distance Robot-Assisted Heart Surgery and Beyond

Doctor operating the CorPath GRX in the interventional cockpit. Image source: Corindus

According to WHO, cardiovascular disease is the leading cause of death globally, claiming 17.79 million lives each year.

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“Either remote or go home”

Since the launch of the CorPath robotic platform, the Corindus team has been considering how to provide treatment to patients in need around the world at any time, while also striving to offer more safety assurances to doctors.

Although CorPath’s advanced robotic technology provides physicians with exceptional precision and control during PCI procedures, the system still needs to do more to protect physician health—imaging techniques used during PCI expose them to radiation, and wearing heavy protective gear can lead to orthopedic injuries.

“Corindus sensed that an opportunity was at hand to improve surgical safety for surgeons while meeting the growing demand for innovative global telemedicine solutions, so the company CEO Mark Toland told our team that a decision had to be made immediately, ‘either remote or go home.’” recalled Nicholas Kottenstette, a researcher at Corindus. “This battle cry resonated throughout the company, forcing us to push the limits further, expanding the capabilities and possibilities of the CorPath system and achieving another industry milestone: creating the first remote robot-assisted PCI.”

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Aircraft control technology facilitates the birth of robotic surgery

Kottenstette has been working on the robotic production line since joining Corindus, but his career began in another field. He earned his Ph.D. in electrical engineering from the University of Notre Dame, where he designed a framework for network-controlled systems that ensured system stability while considering time delays and data loss. He then began his personal career at Vanderbilt University—developing robotic control systems for aircraft using model-based design. It was this work that birthed different types of control systems operated over networks: surgical robots.

Kottenstette says: “These jobs, including model-based design using MATLAB® and Simulink®, are integral to the development of our precision robotic systems.”

To understand the complex workings of robotic systems, a basic inventory of their key components will aid your understanding. The system includes two main workstations: the bedside unit—this part operates equipment within the patient, and the interventional cockpit—where doctors manipulate the equipment during interventional procedures.

The bedside unit has an extending arm and a bedside touchscreen. It is operated by the scrub nurse. Image source: Corindus

The interventional cockpit includes a radiation shield, monitors, and a console, allowing interventional cardiologists to work standing or sitting without wearing lead aprons. Image source: Corindus

The CorPath GRX robotic platform includes two main workstations: the bedside unit—this part operates equipment within the patient, and the interventional cockpit—where doctors manipulate the equipment during interventional procedures.

The bedside unit consists of an extending arm, robotic driver, and disposable sterile kits. The arm positions the robotic driver and sterile kits in the appropriate location. The robotic driver receives input from the cockpit console, guiding the sterile kits, which further manipulate the guidewire, balloon/stent catheter, and guiding catheter within the patient’s body.

Interventional cardiologists work in the interventional cockpit, which contains a robotic control subsystem and a remote real-time communication system that connects the physician to the robot in the bedside unit.

“The robotic-controlled workstation contains a control computing system, monitors, networked devices (i.e., connectivity), and a robotic control console with three joysticks.” Dr. Patel says. “The monitors display real-time hemodynamic variables and fluoroscopic video, providing the operator with enhanced visualization of the PCI process. One joystick is used for balloon/stent operation, one for guidewire operation, and the third for guiding catheter operation.”

A close examination of these two main systems—the bedside unit and the interventional cockpit—reveals that collaboration and interdependence are critical to the successful execution of the robotic system. Together, these systems provide quantifiable advantages, including improved accuracy in measuring anatomical structures, better determination of lesion size and stent length, and enhanced precision in stent placement.

“All of this work, including model-based design using MATLAB and Simulink, is integral to addressing the challenges of developing precision robotic systems.”

Dr. Nicholas Kottenstette, researcher at Corindus

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Remote Surgery

Executing complex procedures remotely presents significant design challenges, the primary of which is real-time, end-to-end video capture and processing: when there is noticeable latency between the images the doctor sees over the network and the commands sent, the physician’s operational efficiency may be compromised.Additionally, physicians must be cognizant of the quality of the network connection, including network latency and the number of frames per second received (throughput). Under poor network conditions, the system should limit the physician’s operations to reduce the risk of harm to the patient.

To overcome the challenges of operating real-time systems, Kottenstette utilized model-based design to refresh his innovative record.

“MATLAB, Simulink, and Simulink Real-Time™ have long been a major part of my application development work on the CorPath system, from embedded motor control for guiding robotic arm movements to the communication methods for fluoroscopic images with the workstation, encompassing everything.” Kottenstette says. “My team models remote systems using model-based design.”

This approach has already yielded returns. For instance, when Corindus began developing the next-generation platform CorPath GRX, they used a generic camera, at a time when there was no real-time support for USB 3.0 devices.

“When we were striving to develop advanced real-time video capabilities that would not disrupt the physician’s normal workflow, MathWorks partnered with us to develop the needed support.” Kottenstette says. “Once this capability was developed, we could compress and decompress images as needed for real-time transmission and use by remote operators.”

To ensure dedicated real-time networking capabilities, Corindus employed the Speedgoat series target machines—high-performance computers optimized for specific applications—to execute critical tasks of their system. Placing one Speedgoat target machine at the operation site and another supporting the interventional cockpit at a remote location, the performance of CorPath GRX was impressive.

Dr. Patel noted in his report, “The remote R-PCI process has been successful in every aspect. Remote intervention operators found the functionality of the robotic platform and network connection system comparable to the manual PCI process in the lab, with no noticeable process delays or technical difficulties. The recorded average network latency of 53 milliseconds confirmed this, a delay that operators were unlikely to perceive.”

Kottenstette designed Simulink real-time models to control the bedside equipment.

“MATLAB, Simulink, and Simulink Real-Time have long been a major part of my application development work on the CorPath system, from embedded motor control for guiding robotic arm movements to the communication methods for fluoroscopic images with the workstation, encompassing everything. My team models remote systems using model-based design.”

Dr. Nicholas Kottenstette, researcher at Corindus

Encouraged by the groundbreaking success of the remote R-PCI process, Corindus continues to aim for greatness—great enough to lead the telemedicine revolution in the field of brain disease treatment.

“For stroke patients, every second counts, just as it does for heart patients.” Kottenstette says. “Our remote robotic protocol can treat patients anywhere, which is the trend of future development, and it is also driving the next wave of innovation in treating strokes with CorPath. In the United States, stroke is the leading cause of disability and the fifth leading cause of death.”

Click to read the original English article ↓↓↓

New Frontiers in Telemedicine: Long-Distance Robot-Assisted Heart Surgery and Beyond

Editor: Jin Cheng Editor: Zhang Tong

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