key: cord-0968716-58zfldej
authors: Goel, Sachin S.; Greenbaum, Adam B.; Patel, Apurva; Little, Stephen H.; Parikh, Roosha; Wyler von Ballmoos, Moritz C.; Lumsden, Alan B.; Reardon, Michael J.; Kleiman, Neal S.
title: Role of Teleproctoring in Challenging and Innovative Structural Interventions Amidst the COVID-19 Pandemic and Beyond
date: 2020-04-16
journal: JACC. Cardiovascular interventions
DOI: 10.1016/j.jcin.2020.04.013
sha: ac380c2d346a8618912746fe126b35b7a9315026
doc_id: 968716
cord_uid: 58zfldej

Abstract Teleproctoring can be used successfully in performing challenging and innovative structural heart interventions using sophisticated technology which allows real time bidirectional audiovisual communication with digital transmission of live videos and direct observation of the operative field by a remote proctor. We share an illustrative case that was performed amidst the COVID-19 global pandemic that led to travel restrictions to limit spread of the virus. Teleproctoring has future implications beyond the current global health crisis to facilitate rapid dissemination and exchange of knowledge for ultimately helping patients around the globe.

Teleproctoring can be used successfully in performing challenging and innovative structural heart interventions using sophisticated technology which allows real time bidirectional audiovisual communication with digital transmission of live videos and direct observation of the operative field by a remote proctor. We share an illustrative case that was performed amidst the COVID-19 global pandemic that led to travel restrictions to limit spread of the virus. Teleproctoring has future implications beyond the current global health crisis to facilitate rapid dissemination and exchange of knowledge for ultimately helping patients around the globe. procedure has only been performed at few centers under on-site proctorship.

Accordingly, we invited a nationally renowned pioneer in this technique (AG) to join us as a proctor for the case. Unfortunately, travel to our institution became impossible due to travel restrictions discussed above. During a conference call the night prior to the procedure, we discussed the implications and options for our patient, including cancellation of the case and postponement until travel restrictions could be lifted versus proceeding with remote teleproctoring. Given the patient's progressive symptoms, recent hospitalization for CHF and uncertainty regarding the duration of the travel restrictions, the heart team decided to proceed with the case using remote teleproctoring.

The proctor had prior experience in teleproctoring, and our institution had extensive experience in transcatheter valve replacement as well as the requisite equipment and IT support personnel. The proctor and our team carried out two 60-minute "drills" reviewing the procedural steps as well as review of a similar case their team had performed recently, using

WebEx video conferencing that night and the following morning. Within a few hours' notice, the team was able to coordinate with and send instructions to the proctor to download The VisitOR1 Robot is an FDA-approved Class II HIPAA (Health Insurance Portability and Accountability Act)-compliant telepresence device manufactured by InTouch Health (Santa Barbara, CA) and supported on-site by Karl Storz (Tuttlingen, Germany). The InTouch Provider software used to access these robots is available on Windows PC, iPhone, and iPad devices. As opposed to most commercially available video-calling applications, the InTouch network is encrypted for security and gives the remote user (in this case the proctor) the abilities to view multiple images simultaneously, to zoom, pan, tilt the robot's camera, and to telestrate. Typically, when the robot is connected to a network that meets specific network requirements provided by InTouch Health, the Robot has little to no latency during the session. Since the robot was already on the secure network with the Hospital IT department's assistance, there was no diminution of audio or video transmission during the case. The userfriendly features and reliability of the robot not only enhanced the method of video conferencing but also provided critical information to the proctor in real-time with no lag, and thus led to a favorable teleproctoring experience with a successful clinical outcome.

Although teleproctoring has been developed in other procedure-oriented medical fields, It is important to recognize several caveats. First, the operating team was extremely experienced, having performed approximately 2,000 transcatheter valve replacements over the prior 9 years, and had an established harmonious working relationship. Secondly, the procedure was performed with the participation of an individual who was experienced at proctoring. Most critical, perhaps, the real-time nature of the transmission and its high video quality allow the proctor to be comfortable that his recommendations are translated immediately into appropriate actions. Finally, extensive review of the case and procedure were performed on two occasions prior to the procedure.

Teleproctoring has significant f implications that extend well into the future, including facilitation of rapid dissemination and exchange of knowledge for innovative technical procedures helping patients across the globe. 

World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-10-11

Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID-19) Pandemic: An ACC /SCAI Consensus Statement

Anterior leaflet laceration to prevent ventricular outflow tract obstruction during transcatheter mitral valve replacement

Telemedicine and telementoring in the surgical specialties: A narrative review

Transcatheter electrosurgery: JACC State -of-the-Art Review