Introduction Despite advancements in cardio-intervention device technology and enhanced operator experience, peri-procedure ischemic stroke remains a major and serious complication with increased mortality in patients undergoing transcatheter aortic valve replacement (TAVR). We aimed to use a novel Robotic Transcranial Doppler (NovaGuide Intelligent Ultrasound, NovaSignal Corp., Los Angeles CA USA) with Artificial Intelligence for real-time intraoperative neuromonitoring during TAVR in order to establish the safety and validity of this tool in detecting cerebral emboli and report perfusion outcomes in real-time. We also sought to highlight the critical stages of TAVR in terms of embolic disruption and differences seen between emboli count with and without cerebral protection device, overall providing preliminary data to establish a neuromonitoring tool.

Methods Consecutive patients who underwent TAVR at our institution were identified and consented. Basic demographics and procedural details such as use of sentinel cerebral protection device, type of aortic valve used, and any intra- or post-procedure complications were also noted. In terms of follow-up, comprehensive neurologic examinations were performed post-procedure and at 30-days. For the purposes of identifying crucial parts of the procedure during which most catheter and guidewire activity happens, all procedures were divided into 4 stages; i-) Access to Aortic Arch, ii-) Crossing the Valve and Valvuloplasty, iii-) Valve Positioning and Implantation, and iv-) Removal of Delivery System. Total emboli HITS during the procedure as well as during individual stages were recorded.

Results Twenty-five patients were prospectively enrolled in our study (mean age=80.3±7.3 years; males=15 [60%]). Cardiovascular comorbidities seen were hyperlipidemia in 20 cases (80%), followed by diabetes in 19 (76%). Coronary artery disease was seen in 16 cases (64%) as well. Five patients (20%) had a prior history of stroke or stroke mimics. Mean aortic valve area was 0.82cm² with a mean peak velocity of 3.01±1.15. Balloon assisted valvuloplasty was performed in 3 cases (12%). Cerebral sentinel protection device was used in 12 cases with the rest 13 done with embolic protection. A significantly lower emboli count was seen in cerebral protection group (470.38 vs. 693.33 P=0.01). Valve positioning and implantation were found to be significantly different as well (249.92 vs. 387.5 P=0.01) (Table 1). No stroke events were recorded immediately post-procedure and on 30-day follow-up.

Conclusion In this study, we report our experience using a Robotic Transcranial Doppler (TCD) with Artificial Intelligence as a novel real-time intraoperative neuromonitoring tool in patients undergoing TAVR. By reporting quantity and distribution of high intensity transient signals (HITS) as markers of microemboli during the procedure, we report significantly lower HITS using sentinel cerebral protection. We also identify valve positioning and implantation as the most significant stage in terms of HITS during the procedure.

Disclosures A. Baig: None. C. Manion: None. V. Iyer: None. W. Khawar: None. B. Donnelly: None. A. Monteiro: None. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.