Stephen P. Seslar

Echocardiography and ultrasonography are mainstay imaging modalities for the diagnosis, management, and surveillance of widespread acute and chronic illnesses, including cardiovascular disease. As such, they contribute to improved outcomes. Skilled sonographers are currently required to perform complete diagnostic exams; however, a critical shortage of sonographers in isolated, rural, remote, and global locations contributes to known healthcare disparities. Telerobotic ultrasound systems, which assist sonographers in using a robotic arm to examine patients remotely, offers a potentially profound impact. While this approach represents the intersection of telehealth, robotics, and imaging, important logistics must be addressed to achieve widespread adoption. These include integration of systems and workflow, the need for robust networks, cybersecurity, haptic feedback, cost/billing, and regulatory aspects. The utility, development, technical requirements, and future applications for these technologies are described here.

Background: There are well-recognized challenges to delivering specialty health care in rural settings. These challenges are particularly evident for specialized surgical health care due to the lack of trained operators in rural communities. Telerobotic surgery could have a significant impact on the rural–urban health care gap, but thus far, the promise of this method of health care delivery has gone unrealized. With the increasing adoption of telehealth over the past year, along with the maturation of telecommunication and robotic technologies over the past 2 decades, a reappraisal of the opportunities and barriers to widespread implementation of telerobotic surgery is warranted. Here we report the outcome of a rural telerobotic stakeholder workshop to explore modern-day issues critical to the advancement of telerobotic surgical health care. Materials and Methods: We assembled a multidisciplinary stakeholder panel to participate in a 2-day Rural Telerobotic Surgery Stakeholder Workshop. Participants had diverse expertise, including specialty surgeons, technology experts, and representatives of the broader telerobotic health care ecosystem, including economists, lawyers, regulatory consultants, public health advocates, rural hospital administrators, nurses, and payers. The research team reviewed transcripts from the workshop with themes identified and research questions generated based on stakeholder comments and feedback. Results: Stakeholder discussions fell into four general themes, including (1) operating room team interactions, (2) education and training, (3) network and security, and (4) economic issues. The research team then identified several research questions within each of these themes and provided specific research strategies to address these questions. Conclusions: There are still important unanswered questions regarding the implementation and adoption of rural telerobotic surgery. Based on stakeholder feedback, we have developed a research agenda along with suggested strategies to address outstanding research questions. The successful execution of these research opportunities will fill critical gaps in our understanding of how to advance the widespread adoption of rural telerobotic health care.

Initial Experience with a Novel Pericardiocentesis Training Simulator Incorporating a Three-dimensional Printed Cardiac Model

Objectives. We compared virtual-reality guided versus fluoroscopy-guided transseptal puncture by novice and experienced operators in a cardiac phantom. Outcome measures included accuracy, time, transseptal path distance, and a survey of the operator experience. Methods. A transseptal simulator was created using a Plexiglas case and a 3D-printed cardiac phantom with a replaceable fossa ovalis, a customized support, and an electromagnetic tracking system. A precisely registered virtual-reality rendering was constructed. from Journal of Invasive Cardiology.

We consider the problem of locating a point-source heart arrhythmia using data from a standard diagnostic procedure, where a reference catheter is placed in the heart, and arrival times from a second diagnostic catheter are recorded as the diagnostic catheter moves around within the heart. We model this situation as a nonconvex feasibility problem, where given a set of arrival times, we look for a source location that is consistent with the available data. We develop a new optimization approach and fast algorithm to obtain online proposals for the next location to suggest to the operator as she collects data. We validate the procedure using a Monte Carlo simulation based on patients’ electrophysiological data. The proposed procedure robustly and quickly locates the source of arrhythmias without any prior knowledge of heart anatomy.

Background: Despite data supporting the use of simulation training in procedural specialties and accreditation requirements, few options exist for electrophysiology (EP) training. We aimed to develop a low‐cost, accessible simulator for training in EP mapping, and to test the simulator in a group of novice users.Methods: Our mapping simulator is composed of three components: an acrylic case representing torso and thigh; three‐dimensional (3D) printed cardiac models; and a commercially available mapping system. Using a proprietary flexible material that mimics the consistency of human heart tissue, we created an anatomically accurate model of a normal right atrium (RA) from computed tomography data. We developed a test protocol consisting of two activities: creation of a RA shell and timed navigation to specific locations within the RA shell. Seventeen participants were randomized to either practice versus no practice on the simulator, and repeated simulator and self‐assessment tests were performed after 1 week. We measured volume of the RA map and time taken and distance from the target sites for each target location.Results: Both groups showed improvement in generation of geometry, volume, time to target, and self‐assessed comfort level after initial exposure to the simulator. Compared with no‐practice, the practice group demonstrated an improved sense of confidence in mapping.Conclusions: Focused training in EP mapping using a novel simulator created with 3D printed heart models and a standard mapping system is feasible for use in the training environment. Exposure to the simulator is associated with improved mapping skills and trainee comfort level.

In critically ill children, multi-organ-system disease can influence the choice of antiarrhythmic medication. Intravenous therapy is often necessary. There is a scarcity of paediatric critical-care cases demonstrating the dosing, monitoring, and efficacy of intravenous sotalol. This case demonstrates the effective use of intravenous sotalol in an adolescent with renal, hepatic, and haematological dysfunctions.

Background: Adults with high premature ventricular contraction burden can develop left ventricular dilation, dysfunction, and strain, consistent with a cardiomyopathy, which is reversible with radiofrequency ablation of the premature ventricular contractions. Evidence in children with similar ectopy burden is limited. We performed a single-centre retrospective review to examine the prevalence of premature ventricular contraction-induced cardiomyopathy, natural history of ventricular ectopy, and progression to ventricular tachycardia in children with frequent premature ventricular contractions.Methods: Children aged between 6 months and 18 years, with premature ventricular contractions comprising at least 20% of rhythm on 24-hour Holter monitor, were included in our study. Those with significant structural heart disease, ventricular tachycardia greater than 1% of rhythm at the time of premature ventricular contraction diagnosis, or family history of cardiomyopathy – except tachycardia-induced – were excluded. Cardiomyopathy was defined by echocardiographic assessment.Results: A total of 36 children met the study criteria; seven patients (19.4%, 95% CI 6.2–32.6%) met the criteria for cardiomyopathy, mostly at initial presentation. Ectopy decreased to <10% of beats without intervention in 16.7% (95% CI 4.3–29.1%) of the patients. No patient progressed to having ventricular tachycardia as more than 1% of beats on follow-up Holter. Radiofrequency ablation was performed in three patients without cardiomyopathy.Conclusions: Our study demonstrates a higher prevalence of cardiomyopathy among children with high premature ventricular contraction burden than that previously shown. Ectopy tended to persist throughout follow-up. These trends suggest the need for a multi-centre study on frequent premature ventricular contractions in children. In the interim, regular follow-up with imaging to evaluate for cardiomyopathy is warranted.