Intuitive in cardiac: What does it really mean?
- Steve Bell
- 6 hours ago
- 10 min read
The first ever robotic cases I saw at the end of the 1990’s were in cardiac. I went to Leipzig to see Prof Mohr do Intuitive valve cases. I was in London with Prof Magdi Yacoub when we had computer motion to do cardiac cases (yes computer motion became part of Intuitive.) What I’m saying is that Intuitive actually started in cardiac “They aimed for the heart and hit the prostate” is the very famous quote.
As part of Cardiovations at JnJ - we acquired Heartport to do endovascular cardio pulmonary bypass (CPB) - and we evaluated the purchase of Intuitive - based on Cardiac. And thought of putting that all together.
Intuitive has a deep and profound experience in cardiac surgery. And although I could never find anything official - the entire Intuitive control paradigm seems to be based on looking through Cardiac Loops and holding cardiac instrument handles. (Ever wondered where the finger pinch design came from?)
Intuitive had an incredible catalogue of cardiac specific instruments - and specialist devices including stabilisers, and atrial retractors. Much of this was really focused on the Si catalogue.
With the advent of the Xi they seemed to move away from Cardiac (the growth was slow, low and difficult) - cardiology was booming and simpler cases were drying up for cardiac surgeons. And explosive growth was in general surgery and gynaecology. I think it made utter sense to focus efforts on the other specialties from a commercial standpoint.
Cardiac Surgery is difficult and inherently risky
Let me delve in a little bit about the cardiac robotics space - and help some of you to understand some of the challenges - and why in some ways keeping the chest closed is counter intuitive.
Firstly you need to understand some of the main procedures of a cardiac surgeon. One is coronary bypass. This is where one of the vessels that supplies blood to the heart gets blocked. The heart tissue risks to die from hypoxia (classic heart attack!). So a secondary vessel is used to jump over the blockage - either by using bloodlflow from another artery (the Internal mammary arteries being the gold standard for the LAD - left anterior descending artery. Or RMA right mammary artery for the RCA Right coronary artery.)
But often we see radial arteries or veins from the leg used as “conduits” to make jumper blood vessels.
Now - many of the simpler CABGs (coronary artery bypass graft) patients have disappeared as interventional cardiologists have been able to cross the blockage for the inside with stents. So now - today - a lot of the CABGs that arrive at Cardicac surgeons are complex multi vessel - post stenting “full metal jackets.” Requiring 3 or 4 bypass grafts.
Similarly - Valves were always fixed by cardiac surgeons in the past. The Aortic Valve - the Mitral Valve the Tricuspid Valve - all fair game for repair of replacement in an “open heart surgery.”
But many of these cases have slowly moved to trans-catheter replacements or repairs. And more newer valve systems are arriving.
I won’t go too deep today - as it’s technical and not for this post.
So the standard was to get access to the heart via a sternotomy (split the sternum down the middle) or MidCab - via the ribs - that was used in beating heart surgery. I’ll explain.
For many heart procedures you have to open the heart. Or do a very fine anastamosis of blood vessels for a CABG (the blood vessel is jumping around as the heart beats) - often on the back of the heart (PDA posterior descending artery). And they all required the heart to be stoped (for anastomosis) and for valves - divert the blood away for a clean field. You could not have the whole cardiac output being squirted into your face. Quick reminder - two circuits for the heart - a smaller low pressure one that send blood to the lungs to get it oxygenated - and the a bigger circuit that pumps blood around the body with a bit higher pressure. Twin circuits. And if you want to stop the heart and bypass it you need to bypass the heart and lungs and have a machine do oxygenation and blood pumping.. The “Bypass machine” as often called. And confusingly mixed with bypass - the procedure for bypassing the coronaries. I digress.
So you “crack the chest” bypass the blood supply to the heart and lungs - stop the heart - do your procedure - start the heart and remove the bypass machine.
That bypass machine requires several complex cannulas to draw the blood out - circulate - put it back in and set up a reverse blood supply to the heart so it doesn’t die (cardioplegia.)
This is a lot easier if you open the chest and get get your hand in. (It also needs all kinds of cross clamps. Big clamps.
So why keep the chest closed?
Actually a good question. Interestingly a sternotomy is not as bad a wound as many think - except the scar. But if you’re an 80 year old man you may not care that much about the scar. The sternum is wired shut and is a relatively good and stable wound.
But…
The healing happens well if it has good blood supply… so if you use the internal mammary artery for your bypass, you do drop the blood supply to the sternum and risk more wound healing complications. If you use both mammary arteries (on either side )you really start to add risk to the wound healing of the sternum. And if a sternotomy does break down… it’s a nightmare. Now sternotomy does mean patients stay in the hospital longer (hmm not 100% correct but…)
And a sternotomy compared to what interventional cardiologists do feels quite brutal. There was rivalry between the two camps you might know.
So the thought was back in the late 90s - how do we avoid a sternotomy?
the simple way was to take out a bit of a rib and work through a small window in the chest - MIDCAB.
For CABG… avoid the need to do by pass and just hold the heart still - stabiliser (beating heart surgery)
Or work thorascopically between the ribs - BUT this has major challenges of dexterity and - putting the patient on the bypass machine.
To do a minimally invasive valve repair you still needed to get the patient on bypass. Now to do that in the standard way required an open chest via sternotomy. So to do it closed chest there was a rethink. Instead of going straight to the vena cava - aorta - pulmonary vessels direct with cannulas - Heartport invented a way do do this all the peripheral arteries and veins via endo cannulas.
Trust me - this is no simple thing to do and unless a team has had significant training it is high stakes. But if you want to stop the heart - open the heart - then this is the option. And it was expensive - time consuming - high risk and very difficult. Floating the cardioplegia cannula retrograde gave me sleepless nights.
But the benefit was no sternotomy - stable field - bloodless field - which was ideal for endoscopic cardiac procedures like mitral valve repair or replacement. BUT it was really hard with standard laparoscopic instruments and rigid fixed instruments.
This is where the robot (an amazing suturing machine) with 7DOF wrists was just the answer. Da Vinci was an enabler in these complex closed chest cardiac procedures. Think of sewing a valve in place.
But expensive - long learning curves - having to have the whole team learn the closed chest bypass - or beating heart techniques. And all being ready for an emergency sternotomy should the shit hit the fan.
It was scary some days.
And I can tell you - unless your robot is stable - precise - and never faults - do not go there. It’s scary enough in thoracic - in cardiac… another ball game. That’s why it has it’s own regulatory pathway - even if you can do robotic thoracic procedures.
So what is happening now?
Roll forwards to 2026 and we see Darla Hutton in charge of the Cardiac division with DV5 cardiac approvals (and more I suspect). This is going to be a system approach - procedure approach - training approach - and data data as a division.
We see this week regulatory clearances for 9 cardiac procedures:
Mitra Valve Replacement & Repair
Tricuspid Valve Repair IMA take down (internal mammary artery)
Left Atrial Appendage closure
Epicardial pacing lead placement
Atrial septal defect repair
Atrial myxoma excision
Patent foramen ovale closure
I will not cover them one by one - But some of these can be done on a beating heart - some require cardiopulmonary bypass. The DV5 doing these avoids a sternotomy in most cases.
Why now? Why the revival?
Well firstly there are still hundreds of thousands of non interventional cardiology patients that need these procedures. They get open heart surgery today and much of this could be done avoiding the sternotomy. And as a cardiac surgeon it offers less complications - less scarring - potential faster recovery and lower length of stay. But very important a faster return to normal life activity - which is important in these patients. Lyng in a bed - or being immobile is not good for them. Get them walking.
Oh and SSi with Sudhir the CEO who is a cardiac surgeon - is making gains in India and starting to show very good cardiac procedures - specialist cardiac instruments - and tele robotic cardiac cases. It’s getting back in vogue.
Let us not forget a few things about cardiac surgeons:
They have immense power in a hospital.
They bring in big money for the hospital and big profit.
They will NOT be sharing the GYNs robot… no way. So this opens up hundreds if not thousands of new install opportunities for the DV5 (as Gen surge and Gyn and Urol gets saturated.)
The I&A price per case (instruments and accessories) could be well higher. The new imaging system (probably called JURA) I speculated to be dropping soon will be ideal in cardiac - if you can see perfusion real time — ohhhhhh
So you put this together and it is a lucrative - relatively untapped market - with high I&A revenues and good reimbursement.
Motivated surgeons. Powerful motivated surgeons. AND as we get more bilateral IMA repairs - AND a refocus on structural heart - AND the advent of endo cardiac robotics - we start to see a big strategy.
The Big Play in Cardiac Robotics
This is NOT a procedure expansion. It is a deep strategy that sets Intuitive up for a very interesting multi year play.
Today DV5 9 procedures - a bunch of standard non force feedback instruments - standard imaging.
Now I will speculate so don't hold me to this...
Next - the revival of the cardiac specific instruments non - force feedback
Next - JURA imaging with multispectral vascular imaging
Next - Cardiac specific force feedback instruments
Next - AI assistive cardiac procedures (I’ll cover this in another post but AI has a lot of uses here)
Next - Endo cardiac ION
Next - Endo cardiac / chest based rendezvous
Oh and maybe a smattering of Single port sub-typhoid stuff in there - but that is for a later day.
Next - specific cardiopulmonary technology - robotic? (Okay super speculative…) oh hang on where did a lot of those old Heartport patents go…
From Gemini: I’m lazy —- “In April 2000, Intuitive Surgical entered into a definitive agreement to exclusively license several patents from Heartport, Inc..
The key details of this deal included:
Cost: Intuitive paid $3.0 million in cash for the licenses.
Technology Focus: The licensed intellectual property primarily covered minimally invasive cardiac surgery techniques and devices.
Specific Applications: Patents often cited in this context relate to heart stabilisation (for beating-heart surgery), tissue retraction, and cardiac valve treatment.
Strategic Value: This acquisition was critical for Intuitive to expand its da Vinci® Surgical System capabilities into robotic-assisted heart procedures by leveraging Heartport's foundational "Port-Access" methods.
This agreement was part of a larger trend of IP consolidation in the early 2000s, helping Intuitive secure its market position against competitors like Computer Motion (whom they later merged with). “
But also JNJ still has a lot of them - many expired but…. They have ‘em.
So the big play here is not to “add some more procedures” but to create yet another strategic wall. And this one is very very very high. You see in contracting and tenders they will now stipulate - CardioVascular procedures. And I can tell you… for other companies to just get the standard procedural expansion is long and hard. To go take on the cardiac procedures - so far out. Ohhhh that is massive. But by then purchasing decisions will have been made - and a hospital that has one DV for Urology - one for Gen surg and now one for Cardiac (the only one that can be bought) - it is a lock in.
You then add in my speculative endo cardiac robotics - and the new imaging - and this is a barrier beyond belief. And they will be learning and learning from analysts to fuel their AI and autonomy. It is quite genius.
The final thought on Intutive in Cardiac with DV5
I live in Italy and my kids all learn about Machiavelli at school. Now I’m not saying that Intuitive would in any way see this as a way to say “If you come on my turf… I go after yours…” but they could see it that way in my kid’s school.
Medtronic does cardiac - gen surg
JNJ has ventured deeper into cardiac - and they do gen surg
Contracting starts to look across things like cardiac and gen surg (it’s convoluted but…)
So it is also natural for Intuitive to be in cardiac (again) to ensure they are facing off against the other two that are encroaching on their turf. I can’t promise that this is real - but as a Medtech strategist - I’d be getting strong in Cardiac again.
The upside is a bunch of new DV5 installs. A set up of a cardiovascular commercial team ready for future robots . An expansion of I&A and a very good use of their JURA system (IF it comes out…). And it is the pathfinder for a series of major upgrades over the next 5 to 10 years - including - my big speculation of Cardiac ION. (Oh and how’s Capstan doing?)
But hold your horses. I already read that this is the demise of all the other cardiac companies like Boston Scientific, Edwards, Medtronic. But it's not. Their technologies are heavily on percutaneous - endovascular - technologies. And a revival by Intutive does not mean they all go away. Instead the hundreds of thousands of open cases that could be done with a closed chest are now possible.
If you read what I say above - there is a mountain to climb in cardiac to get robotic procedures to be done. A vast amount of training, education and support. So do not expect a sudden massive blip in 2026. Each install will need to be done carfully and with purpose. Even for those centres experienced in robotic cardiac. So read this all with "exciting" but not fast.
All speculation and all for educational purposes only.
