LAUSR

Uses of robotic technology continue to expand. Advantages include consistency of task performance and reducing human fatigue and injury. Not surprisingly, the application of robotics to medicine continues to evolve, particularly in surgery for similar reasons with the additional benefit of streamlining certain surgical procedures including cardiac surgery and percutaneous coronary intervention [PCI]). Specific to interventional cardiology, robotic PCI has been demonstrated to be feasible and effective over the last decade with continuing evolutions. Much of the enthusiasm and potential benefits have been relative to reducing operator occupational hazards related to reduced radiation exposure and orthopedic injury by reduced radiation exposure and the need for heavy radiation protection. The impact of this technology on operator procedure performance, while still under evolution, the overall impact seems favorable. An early operator concern was the loss of tactile skill, but operators who train physicians in intervention have realized that they can anticipate technical issues while visually observing a trainee suggesting that much of tactile skill is likely visual. In addition, newer iterations of the robotic technology for interventional cardiology continue to evolve beyond operator‐directed, remote guidewire, and interventional device advancement. Second‐generation systems now additionally allow guide catheter advancement and manipulation as well as built‐in haptics which support the operator by anticipating needed next steps. Such an example is the machine recognition that if an operator pulls back a guidewire, likely the wire has entered an incorrect vessel prompting the robotic drive system to automatically reorient the wire direction 180 degrees to increase the probability that the guidewire will now be more appropriately directed to enter the desired side branch or distal vessel. The availability of haptics assistance may be viewed as “unnecessary” by experienced, high volume interventionalists but such technology has the potential to “level the playing field” for lower volume, less experienced interventionalists, thus creating a more predictable procedure success including less procedure time as well as reduced patient radiation. In addition, the system has safety “stops” which likely minimize vessel injury from excessive force during often frustrating repeated failures to succeed with needed wire or device manipulation. Such measures are not foolproof but can significantly contribute to a more consistent PCI result across variable operator skill and experience. In the accompanying manuscript by Joseph et al., the authors report successful robotic application to coronary angiography. The study is limited as a single‐center experience with a limited number of patients selected based on a low probability of anatomic challenges. Despite those limitations, the results were impressive based on achieving 100% success as defined without complications. While the success may seem limited it does as the authors point out raise interesting potential opportunities for safely expanding access to invasive coronary patient management in remote, low coronary procedure volume areas. Such areas are important as the authors detail the recognized lack of patient opportunity for treatment particularly related to acute myocardial infarction and acute coronary syndrome management. Opportunities include local safe expansion of procedures as well as potentially remote operator procedures. All of this remains in evolution but offers important opportunities for investigation as a method to decrease geographic disparities. Included in future studies should be an assessment of specific technical aspects of procedures. For instance, in a relatively recent NCDR assessment of operator experience and outcomes, the study revealed more frequent low‐volume operators in areas of lower population density. Lower volume operators tended to work in lower volume hospitals and use less radial access with higher radiation exposure and somewhat higher mortality rates. Thus, the research focus should be to determine if utilizing robotic support, overall patient outcomes can be enhanced. In summary, while the initial advantages of robotic PCI have focused on operator safety, “stepping back” from the catheterization