Background Periprocedural ischemic stroke remains a serious complication in patients undergoing transcatheter aortic valve replacement (TAVR). We used a novel robotic transcranial Doppler (TCD) system equipped with artificial intelligence (AI) for real-time continuous intraoperative neuromonitoring during TAVR to establish the safety and potential validity of this tool in detecting cerebral emboli, report the quantity and distribution of high intensity transient signals (HITS) with and without cerebral protection, and correlate HITS occurrence with various procedural steps.
Methods Consecutive patients undergoing TAVR procedures during which the robotic system was used between October 2021 and May 2022 were prospectively enrolled in this pilot study. The robotic TCD system included autonomous adjustment of the TCD probes and AI-assisted post-processing of HITS and other cerebral flow parameters. Basic demographics and procedural details were recorded. Continuous variables were analyzed by a two-sample Mann–Whitney t-test and categorical variables by a χ2 or Fisher test.
Results Thirty-one patients were prospectively enrolled (mean age 79.9±7.6 years; 16 men (51.6%)). Mean aortic valve stenotic area was 0.7 cm2 and mean aortic–ventricular gradient was 43 mmHg (IQR 31.5–50 mmHg). Cerebral protection was used in 16 cases (51.6%). Significantly fewer emboli were observed in the protection group than in the non-protection group (mean 470.38 vs 693.33; p=0.01). Emboli counts during valve positioning and implantation were significantly different in the protection and non-protection groups (mean 249.92 and 387.5, respectively; p=0.01). One (4%) transient ischemic attack occurred post-procedurally in the non-protection group.
Conclusion We describe a novel real-time intraoperative neuromonitoring tool used in patients undergoing TAVR. Significantly fewer HITS were detected with protection. Valve positioning–implantation was the most significant stage for intraprocedural HITS.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Contributors Conception and design: AAB, VSI, AHS. Data acquisition: AAB, WIK, BMD. Data analysis and interpretation: all authors. Drafting the manuscript: AAB. Critical revision: all authors. Reviewed submission: all authors. Guarantor AHS.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests LNH: Grant/research support: Canon Medical; major stock shareholder/equity: Boston Scientific, Imperative Care, Ostial, Synchron, Spinnaker, Serenity, Cerebrotech, Reist. JMD: Consulting fees, payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events: Medtronic, Rapid Medical; support for attending meetings and/or travel: Medtronic, Rapid Medical; patents planned, issued, or pending: QAS.ai; participation on a Data Safety Monitoring Board or Advisory Board: NIH NIHDS Strokenet; stock or stock options: Synchron, Cerebrotech, QAS.ai. EIL: Shareholder/ownership interest: NeXtGen Biologics, Rapid Medical, Claret Medical, Cognition Medical, Imperative Care, Rebound Therapeutics, StimMed, Three Rivers Medical; patent: Bone Scalpel; honorarium: Medtronic, Penumbra, MicroVention, Integra; consultant: Clarion, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, StimMed, Misionix, Mosiac; Chief Medical Officer: Haniva Technology; Advisory Board: Stryker, NeXtGen Biologics, MEDX, Cognition Medical, Endostream Medical, IRRAS AB. AHS: Grants or contracts: Co-investigator for NIH - 1R01EB030092-01, Project Title: High Speed Angiography at 1000 frames per second; Mentor for Brain Aneurysm Foundation Carol W Harvey Chair of Research, Sharon Epperson Chair of Research, Project Title: A Whole Blood RNA Diagnostic for Unruptured Brain Aneurysm: Risk Assessment Prototype Development and Testing; consulting fees: Amnis Therapeutics, Apellis Pharmaceuticals, Boston Scientific, Canon Medical Systems USA, Cardinal Health 200, Cerebrotech Medical Systems, Cerenovus, Cerevatech Medical, Cordis, Corindus, Inc., Endostream Medical, Imperative Care, InspireMD, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Peijia Medical, Penumbra, Q’Apel Medical, Rapid Medical, Serenity Medical, Silk Road Medical, StimMed, Stryker Neurovascular, Three Rivers Medical, VasSol, Viz.ai; leadership or fiduciary role in other board, society, committee or advocacy group: Secretary – Board of the Society of NeuroInterventional Surgery 2020-2021, Chair – Cerebrovascular Section of the AANS/CNS 2020-2021; stock or stock options: Adona Medical, Amnis Therapeutics, Bend IT Technologies, BlinkTBI, Borvo Medical, Bridgewater Ventures, Cerebrotech Medical Systems, Cerevatech Medical, Code Zero Medical, Cognition Medical, Collavidence, CVAID, E8, Endostream Medical, Galaxy Therapeutics, Imperative Care, InspireMD, Instylla, International Medical Distribution Partners, Launch NY, Neurolutions, NeuroRadial Technologies, NeuroTechnology Investors, Neurovascular Diagnostics, Peijia Medical, PerFlow Medical, Piraeus Medical, Q’Apel Medical, QAS.ai, Radical Catheter Technologies, Rebound Therapeutics Corp (purchased 2019 by Integra Lifesciences Corp), Rist Neurovascular, (purchased 2020 by Medtronic), Sense Diagnostics, Serenity Medical, Silk Road Medical, Sim & Cure, SongBird Therapy, Spinnaker Medical, StimMed, Synchron, Three Rivers Medical, Truvic Medical, Tulavi Therapeutics, Vastrax, VICIS, Viseon, Whisper Medical, Willow Medtech; other financial or non-financial interests: National PI/Steering Committees: Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial and CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, COMPASS Trial, INVEST Trial, MIVI neuroscience EVAQ Trial; Rapid Medical SUCCESS Trial; InspireMD C-GUARDIANS IDE Pivotal Trial.
Provenance and peer review Not commissioned; externally peer reviewed.
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