Insights Series Issue 30: "The case for robotic-assisted PCI"

Insights Series Issue 30 siemens-healthineers.com/ insights The case for robotic-assisted PCI What is the value for healthcare executives? A thought leadership paper on “Delivering high-value care” SIEMENS Healthineers Preface The Insights Series The Siemens Healthineers Insights Series is our preeminent thought leadership platform, drawing on the knowledge and experience of some of the world’s most respected healthcare leaders and innovators. The Series explores emerging issues and provides you with practical solutions to today’s most pressing healthcare challenges. We believe that increasing value in healthcare—delivering better outcomes at lower cost—rests on four strategies. These four principles serve as the cornerstones of the Insights Series. Expanding Transforming Improving Digitalizing precision care patient healthcare medicine delivery experience Our Insights portfolio is an integrated collection of events, speaking engagements, roundtable discussions, and an expanding array of print and digital platforms and products all carefully curated to share ideas, encourage discussion, disseminate original research and reinforce our position as a healthcare thought leader. Please visit siemens-healthineers.com/insights-series Executive summary Around the world, the population is growing, and it is The R-PCI system aims to enable less experienced growing older. There are more of us, and we are living cardiologists to perform interventions that previously, longer. Hand in hand with those two facts comes another: only more experienced physicians would attempt. cardiovascular artery disease, one of the leading causes It also protects cath lab interventionalists from workplace of death globally, is on the rise. When intervention is hazards such as dangerous exposure to radiation and required, a gold standard treatment for treating this the orthopedic damage that can result from wearing condition is percutaneous coronary intervention (PCI), protective heavy lead. R-PCI helps set healthcare organizations whereby cardiologists use a catheter to insert one or apart, marking them as suitable destinations of choice more stents in order to open narrowed coronary arteries. for both patients needing PCI, and physicians looking for the best place possible to ply their trade. Historically, PCIs have been performed manually, a feat of precision and expertise that is a testament to the skill Any move to R-PCI could be seen as a disruptive one, and of the interventionalists who perform them. The fact is, should certainly only be undertaken in conjunction though, that the demands that manual PCI places on with an open dialogue involving the head of cardiology human dexterity and visual acuity are such that occasionally, and the appropriate executive suite members. challenges arise that can cost organizations time and money, physically affect physicians, and sometimes even result in negative patient outcomes. Those challenges are as follows: 1. Limited human precision and visualization 2. Variability of care 3. Threats to the health and safety of physicians 4. Limited technology differentiation for attracting talented physicians and patients This paper explores a potential solution to those challenges. Robotic-Assisted PCI (R-PCI) takes the human judgment, intuition and decision-making of cardiologists and combines it with robotic precision, control, and procedural automation. The movements of the catheter, the guidewire, and the balloon or stent are controlled by the interventional cardiologist, but they are executed by a robot that doesn’t get tired, doesn’t get uncomfortable, doesn’t feel stress, and doesn’t get distracted. Siemens Healthineers Insights Series · Issue 30 4 Introduction Relevance of PCI today, and going forward Coronary artery disease is one the most common cardio- Historically, PCIs have been performed manually, by inter- vascular diseases and is among the leading causes of death ventionalists possessing extraordinary deftness and skill. globally. When it comes to treatment for this condition, But the sheer complexity of the job, and the overwhelming a common procedure, widely accepted as a gold standard, precision that is often required, from time-to-time result is percutaneous coronary intervention (PCI). Formerly in difficulties. And these difficulties sometimes affect known as angioplasty with stent, PCI usually involves using patient outcomes. a catheter to insert one or more stents to open narrowed coronary arteries. This paper examines various challenges associated with manual PCI, and then explores a potential solution—a It should come as no surprise that with populations every- rapidly emerging alternative to the complex, demanding where growing and aging, heart disease as well as PCIs procedure so many patients rely on today. The deployment are on the rise. There are now more than one million PCIs of robotic-assisted PCI (R-PCI) offers an advance in precision, performed around the world every year, and that number safety, and value that healthcare providers and organizations has been increasing since 2013, including a 30% increase would do well to consider, and patients are likely soon to in elective PCI.1 demand. As patients get older and suffer from more comorbidities, PCIs are becoming more complex and demanding. Today, complex PCI procedures account for 40% of all PCI cases, and that number is expected to soon reach 50%.2 These procedures can last as long as two hours, with much of that time dedicated to wiring lesions. This can be an extremely challenging process, particularly when navigating tortuous vascular anatomies or crossing long, calcified lesions. 1.000.000 number of PCIs performed every year.1 30% increase in elective PCI (from 2013 to 2017).1 5 Issue 30 · Siemens Healthineers Insights Series The challenge Notwithstanding its well-recognized value, manual PCI presents challenges for three key stakeholders: the medical team working in the cath lab, the broader healthcare organization, and patients. While there are different ways of thinking about and labelling these challenges, for the purposes of this paper we will group them into four categories: 1. Limited human precision and visualization 2. Variability of care 3. Threats to the health and safety of physicians 4. Limited technology differentiation for attracting talented physicians and patients Siemens Healthineers Insights Series · Issue 30 6 Limited human precision Variability of care and visualization One fundamental challenge with PCI is that it requires Reducing unwarranted variations really is the name of the extraordinary, granular precision in the measurement and game in cath labs where PCIs are being conducted. Variations wiring of a tiny coronary lesion in a moving heart, being can add significant costs and reduce quality of care. As looked at through a screen which is six feet (183 cm) away. noted earlier, 40% of today’s coronary interventions are Little surprise, then, that most coronary lesion lengths considered complex, typically associated with more chances are inaccurately estimated. As a result, two out of three of unwarranted variations, lower rates of procedural success, stents today are inappropriately selected based on visual and higher rates of recurrence or major adverse cardiac assessment.3 Whether too long or too short, neither is events. In a perfect world, interventionalists would all have optimal in providing the best possible patient care. But the same high level of skill, and the same ability to navigate the latter is particularly problematic as these cases require vessels and cross lesions. This is not a perfect world, however. additional stents to cover the full lesion, which raises the Some interventionalists perform far fewer procedures than prospect of overlapping stents—the consequences of which do others, and as is the case with so many things, manual are not yet known. Without question, PCI is a difficult PCI is something you get better at the more often you do it. undertaking, which is underscored by the fact that 9.3% of As a result, not all interventionalists possess the skills and PCI patients have an unplanned readmission within 30 days.4 experience to perform complex PCI. This is borne out in the numbers. Patient mortality is 28% higher for low-volume Precision matters operators performing PCI in low-volume hospitals than for high-volume operators performing PCI in high-volume The incorrect sizing and/or placing of a stent hospitals.6 more than doubles the likelihood that a patient will need a repeat procedure within one year and triples their likelihood of suffering The shortage of high-volume interventionalists at some a myocardial infarction within one year.5 institutions can mean patients have to wait a long time for their PCI, and in some cases, they must be referred to other institutions, which is lost income and lost opportunity for the hospital that had to refer them. Patient mortality is 28% higher for low-volume operators * Low-volume operators perform 44% of PCIs Low: <50 PCIs/year; n 1/4 4,628 Annual PCI operator volumes in the U.S.6 Intermediate: 50 to 100 PCIs/year; n 1/4 3,001 High: >100 PCIs/year; n 1/4 2,867 1,500 1,000 500 0 0 50 100 150 200 250 300 350 400 450 500 550 600 650 * Patient mortality is 28% higher for low-volume operators performing PCI in lowvolume (y) Number of Operators hospitals than for high-volume operators performing PCI in high-volume hospitals.6 (x) Average Annual Volume 7 Issue 30 · Siemens Healthineers Insights Series Threats to the health and safety of physicians and patients Physicians cath labs experience the highest rates of radiation exposure of all medical professionals. This exposure has been linked Midcareer cardiologists with 8 to 21 years of practice are to serious injuries: subclinical carotid atherosclerosis more likely to report burnout (39%) than were fellows and early vascular aging, cataracts, various bone marrow in training (10%), early-career cardiologists (23%), or late- and thyroid malignancies as well as other different types career cardiologists (28%).7 This should not be a major of cancer. surprise. The cath lab is a hazardous place to work. Physicians and staff face serious occupational hazards on two different Organizations can ill-afford to ignore the health threats fronts. that accompany working in a cath lab. One interventional physician generates $2.4 million in annual income to The first is orthopedic. Because they must wear heavy lead an organization in the U.S..10 If a physician is unable to protect themselves from radiation, many interventional to practice, it is estimated to cost more than $1 million cardiologists end up experiencing frequent orthopedic (direct and indirect costs) to replace him or her.10 issues ranging from lumbosacral and cervical spine problems, as well as hip, knee, and ankle lesions. Indeed, inter- ventionalists are seven times more likely to suffer orthopedic Patients problems than other physicians, and 62.8% of inter- ventional cardiologists report an orthopedic injury during Manual PCI can also pose threats to patient safety. Because their career.8 there is a risk of longer procedures, there is also a risk of increased radiation exposure to patients, along with an The second and even more serious threat comes from increase in contrast media. Contrast-induced acute kidney exposure to radiation. Physicians and staff working in injury represents a common but serious complication of PCI. 62.8% 90% 26% of interventional of cath lab physicians believe it will cardiologists believe that radiation shorten their report an poses a significant career.9 orthopedic injury.8 risk to their health.9 -- Siemens Healthineers Insights Series · Issue 30 8 Mid-career cardiologists Limited technology differentiation report highest prevalence for attracting talented physicians of burnout and more patients Midcareer cardiologists with 8 to 21 years Today’s manual PCI procedure remains largely unchanged, of practice are more likely to report burnout despite advancements in interventional devices. How the (39%) than fellows in training (10%), early-career cardiologists (23%), or late-career procedure is performed looks very much as it did 40 years cardiologists (28%).7 ago. What this means is that there has been little in the way of leading-edge innovation around the procedure that allows physicians and organizations to enhance their reputation and that of their institution. That is a concern for providers both from the standpoint of competing for patients and from the point of view of 28% cardiologist numbers. Interventional cardiologists have a 39% median age of 54 years.11 Organizations are facing a need to start recruiting the next generation of interventionalists, 23% but the lack of innovation around PCI might be an obstacle 10% to that. The health concerns listed above are another barrier. Young doctors, who come from a much more health- conscious generation, are significantly less eager to expose Cardiologists with 8 to 21 years of practice themselves to harmful levels of radiation or to wear heavy Fellows in training lead coverings that might well end up ruining their spines. Early-career cardiologists Late-career cardiologists Elongating physician careers and making it possible for them to practice medicine safely is a growing concern. Recruitment in sight Organizations are facing a need to start recruiting the next generation of interventionalists. 9 Issue 30 · Siemens Healthineers Insights Series The solution The evidence above underscores the need for improvement Support to operators in contemporary PCI practices and technologies. Fortunately for healthcare organizations today, that improvement is R-PCI system helps operators by enabling robotic precision, control, and procedural within their grasp. automation. It aids in selection of the appropriate stent and helps to ensure The solution is to take the best in human judgment, intuition accuracy in device-positioning. and decision-making and combine it with robotic precision, control, and procedural automation. Robotic-assisted PCI does precisely that. It emerged as a technology transformation 10 years ago, designed to help overcome the key challenges inherent in manual PCI procedure. Today, there are Robotic Systems, FDA-cleared and CE-marked, that are well-established in early adopter organizations. the catheter, the guidewire, and the balloon or stent. This R-PCI combines a robotic bedside unit with a control unit, level of precision is crucial to the success of the procedure which allows for manipulation of catheters, guidewires, and to the long-term outcome of the patient. With precise and devices, from a short distance away from the procedure anatomical measurements and automated procedural table. Guided by video images from the angiography system movements, the robotic system helps operators navigate into robotic movements and using the control unit/joystick complex anatomies more consistently and predictably, aids and touchscreen controls, the cardiologist can operate in selection of the appropriate stent and helps to ensure the robotic bedside unit in the cath lab, and precisely steer accuracy in device-positioning. Siemens Healthineers Insights Series · Issue 30 10 Manual PCI vs R-PCI R-PCI is not a system that replaces physicians. Rather, it is a system that gives cardiologists the precision, control, and endurance they need to enhance their clinical judgment, intuition, and decision-making. It acts as a co-pilot of sorts, helping cardiologists do their best work. Manual PCI R-PCI ------- The future of healthcare includes robotics Robotic procedures are estimated to grow by 72% globally, surpassing four million by 2025. They were first introduced about 25 years ago in the fields of gynecology and urology.12 Since then, the potential these procedures hold for improved standardization, outcomes and access has seen them gradually take hold in other fields. Robotic surgery is clearly here to stay. 11 Issue 30 · Siemens Healthineers Insights Series “That’s the nice thing about this technology. It is being used for precision, delivery, and control, all key aspects for putting the right stent in the right place . ” 13 Paul T. Campbell, MD Interventional Cardiologist, Atrium Health NorthEast, North Carolina, U.S. Enhanced technical precision The first challenge identified in manual PCI is limited Complemented accuracy technical precision, such as inappropriate stent selection and positioning, as well as the expected risk correlation Cardiologists can determine lesion length and know that they are selecting the right with outcomes. No matter their experience and skill level, stents. the procedures that cardiologists are asked to perform in a cath lab push human boundaries of manual dexterity and eyesight capacity. Which is why the solution seems so obviously to be to delegate pure mathematics, utter precision and complex measuring to computers that were created specifically for these tasks. During the procedure, the robotic system adds extra R-PCI allows for direct measurement of coronary anatomy control and enhanced precision at every step. R-PCI is down to a fraction of a millimeter. What this means is associated with reduced additional stent utilization, that cardiologists can confidently determine lesion length due to a significantly lower incidence of longitudinal and know that they are selecting the right stents. In geographic miss compared to manual PCI—12.2% to addition, the system enables precise stent positioning 43.1% respectively.13 Overall R-PCI has demonstrated with 1mm movements. It doesn’t get tired, it doesn’t get 99.1% clinical success in complex cases, comparable uncomfortable, and it doesn’t get distracted. with manual PCI clinical success and procedure times.14 Siemens Healthineers Insights Series · Issue 30 12 “With the help of created algorithms taken from the best interventional operators you can get rid of the trial and error method for vessel navigation. It is as if Tiger Woods hits a golf ball and we can make the robot hit the golf ball the same way. That way everyone gets the opportunity to play at that high level.” William Lombardi, MD Director, Complex CAD Therapies, University of Washington Medical Center Seattle, U.S. Reducing unwarranted variations The next challenge revolves around the variations that exist from cardiologist to cardiologist, and cath lab to A Standardization support cath lab. These are variations in operator skill, procedure R-PCI with automated movements is designed to replicate the manual techniques, and patient outcomes. These stem, in large techniques of highly skilled operators. measure, from one other important variation—in the number of procedures that interventionalists perform. To improve as an interventionalist and achieve the Overall, more standardized procedures, increased procedural demanding level of skill and precision required for these efficiency and risk mitigation—reduced trial and error— complex procedures, cardiologists must perform them often. give cardiologists greater support and confidence when But in the U.S., for example, the average interventionalist undertaking complex coronary interventions. only performs 50 PCIs per year. Only one in three perform more than 150 per year.15 This gap in procedure volume From an organizational point of view, R-PCI can mean an may lead to variability of care between operators and increase in patient volumes as it reduces or eliminates the institutions. deferrals to other institutions that occur with manual PCI. Current manual methods for navigating vessels and crossing lesions is often referred to as “trial and error”, which says a great deal about its reliability. R-PCI with automated movements is designed to replicate the manual techniques of highly skilled operators, with the intent to help reduce time associated with wiring lesions, standardize procedures, and reduce variability across operators. As an example, −53% pre-clinical trials have shown that the R-PCI time needed to wire lesions can be as much as 53% lower when equipped wiring time: R-PCI with automation with the automated Rotate on Retract movement.16 vs. R-PCI without automation.16* * Disclaimer: Compared to robotic wiring without automation, preclinical study data may not be predictive of clinical results.16 13 Issue 30 · Siemens Healthineers Insights Series “The precision provided by robotic assistance and the reduction in radia- tion exposure can be of fundamental importance.” Holger Nef, MD Vice Chairman Cardiology, University Hospital of Giessen and Marburg Making the cath lab safer for physicians Physicians while sitting at their workstation is that the station is already radiation-shielded. Physicians can also opt to work Beyond the confidence that accompanies the precision, the controls and fluoroscopic imaging from a control area control, and automation of R-PCI, interventionalists outside the procedure room. What this means is that for have a very personal reason for considering the technology— primary operators performing R-PCIs, there is a reduction it makes their workplace less hazardous. As noted above, in radiation of more than 95% compared to their colleagues there are two distinct threats facing cardiologists doing manual PCI while wearing traditional lead. R-PCI performing manual PCI. Robotic assistance eases both. operator head-level radiation is 80.0% less than manual PCI with suspended lead.17, 18 During an R-PCI procedure, cardiologists work from a workstation, comfortably positioned on an ergonomic The current estimate is that a cardiologist performing chair. And for the most part, they are not required R-PCI would be exposed to less radiation in 20 years than to wear lead. This can make a real difference in the lives a manual interventionalist is in just one year.19 of people who once did their jobs from underneath a heavy covering of lead. It can potentially reduce musculoskeletal strain, cut down on orthopedic injuries, Patients and quite possibly prolong careers. From a patient safety perspective, R-PCI creates a safer As for radiation exposure, that too can be significantly environment by reducing 20% their exposure to radiation,20 reduced. The reason operators don’t have to wear lead and by lowering 35% the required contrast media.21 95% 20% less radiation for the less radiation primary operator for the patient Siemens Healthineers Insights Series · Issue 30 14 “Performing interventions from a workstation improves your overall life. It allows you to make better use of your time, for example: When you’re waiting for things, which you often do in a cath lab, working at a workstation allows you to do your procedure notes, your orders, or to catch up on your EMR.” William Lombardi, MD Director, Complex CAD Therapies, University of Washington Medical Center Seattle, U.S. Stand out, or risk falling behind We know that we have a growing and aging population, Institutions that adopt R-PCI have the potential to treat and one of the biggest implications for PCIs is that demand more patients, and physicians deciding which organization for the procedure is going to increase, for many years to to join will almost always choose the one offering the come. Something else we know is that increasingly, best and newest technology. patients are acting as consumers, going where they know they will be well and safely treated, and where they From the point of view of physicians, access to leading can expect the best possible outcomes. Finally, as we noted technologies such as robotic-assisted PCI allows them to above, we know that there is a growing demand for participate in leading-edge clinical innovation, establishing expert interventionalists, in a field where burnout is a them as leaders in clinical practice and enhancing their significant problem. reputation and that of their institution. The opportunity to differentiate the healthcare provider And for patients, who increasingly are inclined to “shop using R-PCI is particularly relevant for organizations around” for the best possible care and the best possible aiming to have, or already having, cath labs positioned experience, they will be attracted to institutions that, as centers of excellence in interventional cardiology, thanks to R-PCI, can offer both. academic hospitals, and for forward-thinking organizations. All of that results in two noticeably clear imperatives for healthcare organizations and providers. Cardiology centers need to attract patients, and the cath lab must become a place where people want to stay, and outsiders want to join. Meeting, and ideally exceeding, the expectations of patients is a priority for all healthcare providers. Meeting the expectations of employees is also key as this affects recruitment and retention. R-PCI is key to delivering on both of those imperatives. 15 Issue 30 · Siemens Healthineers Insights Series The potential economic R-PCI demonstrates impact of R-PCI 15% reduction in stent usage compared to manual PCI The quality benefits of R-PCI—helping protect key personnel • Average number of stents required and potentially reducing the number of complications in robotic-assisted PCI: 1.221 and unplanned readmissions—can also help organizations • Average number of stents required by expanding services into more complex cases, growing in manual PCI: 1.422 patient volumes, and improving staff retention and • 15% savings on stents.21, 22, recruitment. All of this translates into economic benefits. The R-PCI economic impact needs to balance the specific capital/service investment against projected cost savings Financial impact and anticipated revenue growth. Hospitals can expect • savings on stents of as much as 15% due to reduced usage Average price of Drug-Eluting Stent (DES): $1,510 and, a 35% savings in contrast media due to procedural • automation. In addition, there will likely be additional Average price of Bare-Metal Stent (BMS): $670 patient volumes, improved productivity, and lower costs • because of fewer cardiologist sick leaves along with Blended average stent price: $1,300 better staff recruitment, retention, and replacement.22 • Savings for stents per robotic-assisted PCI: $260 The economic impact will vary depending on the specific healthcare system, and the characteristics of each center. One financial model based on U.S. data showed that a R-PCI system has an estimated payback period of approximately 3 years, based on investment, cost savings and revenue $1,820 growth estimations. $1,560 −15% ($260/PCI) Manual PCI Robotic-Assisted PCI Siemens Healthineers Insights Series · Issue 30 16 “This technology has a very bright future. After incorporation of more and more Artificial Intelligence, the technology will make the interventions simpler and simpler. There will be less and less scope for human error.” Tejas M. Patel, MD, DM, FACC, FSCAI, FESC Chairman and Chief Interventional Cardiologist, Apex Heart Institute in Ahmedabad, India The future is here To study the projected future of R-PCI is to open a new Numbers today window on the healthcare of tomorrow. Looking ahead, we can see R-PCI is poised to expand even further as the As of today, R-PCI has been used in approximately 10,000 interventions in field evolves, and the current limitations that are always more than 15 countries around the present with this new technology are gradually overcome. world, including 76 centers in the U.S., This will be accomplished by increased compatibility 15 in Europe and Middle East, and another 15 in Asia-Pacific. with other devices, the ability to manipulate multiple stents or catheters simultaneously, not to mention the real possibility of fully remote PCI procedures, or “tele-stenting,” to address the problem of delivering care to people in remote areas. In addition, there is room for expansion of these robotic platforms to other types of interventions, including neurovascular and peripheral vascular conditions. 17 Issue 30 · Siemens Healthineers Insights Series Conclusion Suggested follow-up on siemens-healthineers.com/insights • Siemens Healthineers Insights Series, issue 31: Robotic technology is becoming increasingly common The future of interventional services— in healthcare. Today there are numerous examples of Advancing robotics in healthcare. Available at: siemens-healthineers.com/ procedures where robots are used to enhance the skills insights/news/future-interventional-services and abilities of humans. We see this in urologic, orthopedic, and gynecologic surgeries. Given this and given what i Information: we know about R-PCI, it would be difficult to frame an argument against considering its potential adoption by The Siemens Healthineers Insights Series is our healthcare organizations with an eye on the future. preeminent thought leadership platform, drawing on the knowledge and experience of some of the R-PCI allows cardiologists to retain full control of the world’s most respected healthcare leaders and procedure but do so in the knowledge that there will be innovators. It explores emerging issues and provides assistance in avoiding visual misjudgments, ability to measure practical solutions to today’s most pressing healthcare challenges. anatomy to help select stent length, and no misplaced stent thanks to millimeter precise positioning. All issues of the Insights Series can be found here: siemens-healthineers.com/insights-series R-PCI is designed to provide low-volume interventionalists with the assistance of robotic techniques that can help Contact: duplicate some of the manual skills of highly skilled operators. For further information on this topic, The process also protects physicians from the workplace or to contact the authors directly: hazards that have existed in cath labs for so long. With Luis M. Lasalvia, MD R-PCI, there is no longer a need for the primary operator Vice President and Global Medical Officer to work under heavy lead, helping reduce the risk of both orthopedic damage and dangerous exposure to radiation. luis.lasalvia@siemens-healthineers.com R-PCI helps set healthcare organizations apart, both by enabling differentiation for attracting more patients needing PCI, and by making the cath lab a safer and more secure place to work. Both differentiators would certainly help attracting physicians looking for the best place possible to ply their trade. Clearly the decision to move to a robotic system could be perceived as a disruptive one, and needs to be made in alignment with the strategic direction of a hospital and its cardiology center, and in an open dialogue involving the head of cardiology and the appropriate executive suite members. Timing and strategy should come together, resulting in an informed and evidence-based decision that fits best for the organization, its staff, and their patients. Siemens Healthineers Insights Series · Issue 30 18 About the author Luis M. Lasalvia, MD Vice President and Global Medical Officer Siemens Healthineers, New York, U.S. Dr. Luis Lasalvia, Vice President and Global Medical Officer, drives for more effective and patient centric healthcare in actual practice, by integrating medicine, technology, and finance. His clinical expertise is coupled with extensive team leader experience in the pharmaceutical and medical device industries. He has covered multiple roles as strategist, practicing physician, deal maker and negotiator, and technology scouter. Entrepreneur and innovator with international background, Luis has participated in projects in more than 50 countries in all continents, innovating, and creating novel and action-oriented insights, by proactively collaborating, and working together with organizations and top leaders around the globe. Dr. Luis Lasalvia has been guest speaker, panelist, and moderator at approx. 500 conferences and events around the world, submitted several patents in the U.S. and Europe, and authored more than 50 papers and articles in peer review journals and other prestigious publications. Medical Doctor (Republic University, Montevideo), Master International Business (Pompeu Fabra University, Barcelona), and Postgraduate degrees in Business Administration and in Marketing. Completed Entrepreneurship, risk management, and innovation executive studies at The Wharton School of Business, New York University, and Harvard Business School. 19 Issue 30 · Siemens Healthineers Insights Series References 1. Rony Lahoud; Harold L. Dauerman. Fall 10. Michael Seymour, Are You Investing in 19. Weisz G, et al. Safety and Feasibility of and Rise of Coronary Intervention Am Cath Lab Worker Health? Cardiovascular Robotic Percutaneous Coronary Heart Assoc. 2020;9:e016853./ Business (accessed 11/13/2021) Intervention: PRECISE Study. J American JAHA.120.016853 College of Cardiol, 2013, Vol 61, No. 15: 11. Arjun Kanwal, et al. The Assimilation of 1596–1600. 2. Fazel R, Curtis J, Wang Y, Einstein AJ, et International Medical Graduates Into al. Determinants of fluoroscopy time for the Cardiovascular Workforce, J Am Coll 20. Patel E., et al. Circ Cardiovasc Interv, 2020. invasive coronary angiography and Cardiol Case Rep. 2020 Mar, 2 (3) percutaneous coronary intervention. 508–512 21. PRECISION GRX Registry – data on file Insights from the NCDR®. Catheter Cardiovasc Interv. 2013;82:1091–1105 12. International Federation of Robotics 22. The Economic Impact of R-PCI (IFR), World Robotics Report 2020, Siemens Healthineers. 3. Campbell PT, et al. The Impact of Precise BIS Research White Paper and data on file. Nov, 2021. Robotic Lesion Length Measurement on Stent Length Selection: Ramification 13. Paul T. Campbell, Cath Lab Digest. 23. Klein LW et al. Occupational health hazards for stent savings. Cardiovasc Revasc Volume 23 - Issue 6 - June 2015. Sanger of interventional cardiologists in the Med. 2015 Heart & Vascular Institute, Concord, current decade: Results of the 2014 SCAI North Carolina. membership survey. Catheter Cardiovasc 4. Ankur Kalra, at al. Percutaneous Coronary Interv. 2015 Intervention Readmissions. JACC: 14. Mahmud E, et al. Demonstration of the Cardiovascular Interventions, Volume Safety and Feasibility of Robotically 24. Crock HV et al. Observations on the 11, Issue 7, 9 April 2018, Pages 675–676 Assisted Percutaneous Coronary management of failed spinal operations. Intervention in Complex Coronary Lesions: J Bone Joint Surg Br. 1976;58:193–199. 5. Marco A. Costa, et al. Impact of Stent Results of the CORA-PCI Study Deployment Procedural Factors on Long- (Complex Robotically Assisted 25. Ebeling U et al. Microsurgical reoperation Term Effectiveness and Safety of Siro- Percutaneous Coronary Intervention). following lumbar disc surgery. Timing, limus-Eluting Stents (Final Results of JACC Cardiovasc Interv. 2017 Jul surgical findings, and outcome in 92 the Multicenter Prospective STLLR Trial) 10;10(13):1320–1327. patients. J Neurosurg. 1989;70:397– The American Journal of Cardiology. 404. doi: 10.3171/jns.1989.70.3.0397. VOL. 101, NO. 12 June 15, 2008 15. Fanaroff AC, Zakroysky P, Dai D et al. p1704–1711 Outcomes of PCI in Relation to Procedural Characteristics and Operator Volumes in 6. Fanaroff AC, et al. Outcomes of PCI in the United States. J Am Coll Cardiol. 2017 Relation to Procedural Characteristics and Operator Volumes in the United States. J 16. Madder R, et al. 2017. Disclaimers: Am Coll Cardiol. 2017 Jun 20;69(24): Compared to robotic wiring without 2913–2924. automation, preclinical study data may not be predictive of clinical results 7. Mehta LS, Lewis SJ, Duvernoy CS, et al. Burnout and career satisfaction among 17. Madder RD, et al. Impact of robotics and U.S. cardiologists. J Am Coll Cardiol. a suspended lead suit on physician 2019:73:3345–3348 radiation exposure during percutaneous coronary intervention. Cardiovasc Revasc 8. Klein LW et al. Occupational health hazards Med. 2017 Apr-May;18(3):190–196. doi: of interventional cardiologists in the 10.1016/j.carrev.2016.12.011. Epub current decade: Results of the 2014 SCAI 2016 Dec 16. PMID: 28041859. membership survey. Catheter Cardiovasc Interv. 2015 18. Weisz G, et al. Safety and Feasibility of Robotic Percutaneous Coronary 9. Data on file. Survey of 50 interventional Intervention: PRECISE Study. J American cardiologists to better understand College of Cardiol, 2013, Vol 61, No. 15: physicians’ awareness and perceptions 1596–1600. of occupational hazards in interventional cardiology. Siemens Healthineers Insights Series · Issue 30 20 At Siemens Healthineers, we pioneer breakthroughs in healthcare. For everyone. Everywhere. By constantly bringing breakthrough innovations to market, we enable healthcare professionals to deliver high-quality care, leading to the best possible outcomes for patients. Our siemens-healthineers.com/ portfolio, spanning from in-vitro and in-vivo diagnostics insights-series to image-guided therapy and innovative cancer care, is crucial for clinical decision-making and treatment pathways. Did you enjoy the read? Make sure to subscribe to Built on a history of innovation going back more than our newsletter to always receive the latest thought 125 years and with unique strengths in patient twinning, leadership insights. precision therapy, as well as digital, data, and artificial intelligence (AI), we are well positioned to take on the All issues of the Insights Series can be found here: siemens-healthineers.com/insights-series biggest challenges in healthcare. We will continue to build on these strengths to help fight the world’s most threatening diseases, improving the quality of outcomes, and enabling access to care. 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