Merging virtual and physical experiences: extended realities in cardiovascular medicine

A virtual patient authoring tool for transcatheter aortic valve replacement

PURPOSE

Computer-based medical training scenarios, derived from patient's records, often lack variability, modifiability, and availability. Furthermore, generating image datasets and creating scenarios is resource-intensive. Therefore, patient authoring tools for rapid dataset-independent creation of virtual patients (VPs) is a pressing need.

METHODS

An authoring tool and a virtual catheterization laboratory environment were developed. The tool allows customised VP generation through a real-time morphable heart model and Euroscore parameters. The generated VP can be examined inside the vCathLab using a fluoroscopy and monitoring device, both on desktop and immersive virtual reality. Seven board-certified experts evaluated the proposed method from three aspects, i.e. System Usability Scale, qualitative feedback, and its performance in VR.

RESULTS

All participants agreed that this method could provide the necessary information and is anatomically correct within an educational context. Its modifiability, variability, and simplicity were well recognised. The prototype achieved excellent usability score and considerable performance results.

CONCLUSION

We present a highly variable VP authoring tool that enhances variability in medical training scenarios. Although this work does not aim to explore didactic aspects, the potential of using this approach in an educational context has been confirmed in our study. Accordingly, these aspects can benefit from a thorough investigation in the future. In addition, our tool can be improved to provide more realistic parameter ranges for procedure-specific cases.

Merging mixed reality and computational modeling for enhanced visualization of cardiac biomechanics

Mixed reality (MR) has the potential to complement numerical simulations for enhanced post-processing and integrate digital models into the daily clinical practice of healthcare professionals. In complex cardiac anatomies, the decision-making process for bioprosthesis implantation involves the challenging analysis of heart valve distribution, positioning, and sealing. This study proposes a framework to visualize computational modeling results in an immersive environment for comprehensive analysis of the geometric implications of implanted devices on human heart function. After computational analysis, the biomechanical behavior of the Living Heart Human Model (LHHM) was used to develop MR content for the immersive visualization of the heart kinematics and the electrical field. Additionally, MR content was developed to assess the spatial implications of left ventricular outflow tract (LVOT) obstruction as observed in transcatheter mitral valve replacement (TMVR). Findings demonstrated that augmented exploration of cardiac biomechanics can be used for a better understanding of the electrical field of the beating heart. In the case of TMVR simulation, MR-related analysis of LVOT obstruction can result in improved visualization and manipulation of 3D anatomies and assessment of device-induced anatomic constraints. We conclude that the synergy between in-silico modeling and MR can potentially enhance physicians' ability to visualize the implications of biomedical device implants in complex cardiac anatomies, benefiting both physicians and simulation experts.

Reporting Guidelines for the Early-Phase Clinical Evaluation of Applications Using Extended Reality: RATE-XR Qualitative Study Guideline

BACKGROUND

Extended reality (XR), encompassing technologies such as virtual reality, augmented reality, and mixed reality, has rapidly gained prominence in health care. However, existing XR research often lacks rigor, proper controls, and standardization.

OBJECTIVE

To address this and to enhance the transparency and quality of reporting in early-phase clinical evaluations of XR applications, we present the "Reporting for the early-phase clinical evaluation of applications using extended reality" (RATE-XR) guideline.

METHODS

We conducted a 2-round modified Delphi process involving experts from diverse stakeholder categories, and the RATE-XR is therefore the result of a consensus-based, multistakeholder effort.

RESULTS

The guideline comprises 17 XR-specific (composed of 18 subitems) and 14 generic reporting items, each with a complementary Explanation & Elaboration section.

CONCLUSIONS

The items encompass critical aspects of XR research, from clinical utility and safety to human factors and ethics. By offering a comprehensive checklist for reporting, the RATE-XR guideline facilitates robust assessment and replication of early-stage clinical XR studies. It underscores the need for transparency, patient-centeredness, and balanced evaluation of the applications of XR in health care. By providing an actionable checklist of minimal reporting items, this guideline will facilitate the responsible development and integration of XR technologies into health care and related fields.

Enhancing medical education for undergraduates: integrating virtual reality and case-based learning for shoulder joint

BACKGROUND

The integration of Virtual Reality (VR) with Case-Based Learning (CBL) has the potential to revolutionise undergraduate medical education, particularly in complex subjects such as the anatomy and rehabilitation of the shoulder joint. This study aimed to explore the effectiveness of this innovative approach in enhancing learning outcomes and knowledge retention.

METHODS

This study employed a parallel-group, assessor-blinded randomised controlled trial (RCT) design. A comprehensive five-week educational programme was developed, combining traditional lecture-based learning with VR-enhanced CBL. The study involved 82 undergraduate students from China Medical University, who were divided into groups receiving different combinations of VR and CBL. Student performance was evaluated through tests and questionnaires.

RESULTS

In the anatomy-related courses, the integration of VR technology with CBL yielded significantly higher results (87.71 ± 5.60) compared to traditional methods (82.59 ± 6.64), with a statistically significant difference (P < 0.05). This provides compelling evidence of VR's potential to enhance student engagement and knowledge retention. In the context of physiotherapy-related courses, however, while the test scores of the VR-combined CBL group (81.85 ± 5.99) were marginally higher than those of the traditional CBL group (79.02 ± 7.57), this difference was not statistically significant (P > 0.05).

CONCLUSION

The present study provides preliminary evidence for the benefits of incorporating VR into medical education, particularly in anatomy. While the results are promising, further research is needed to explore the optimal integration of VR and CBL in rehabilitation studies and to assess their long-term impact on student learning and clinical performance.

TRIAL REGISTRATION

The study was registered with Chinese Clinical Trials Registry (Registration Number: ChiCTR2400089295) on 05/09/2024.

Applications and advances of immersive technology in cardiology

Different forms of immersive technology, such as Virtual Reality (VR) and Augmented Reality (AR), are getting increasingly invested in medicine. Advances in head-mounted display technology, processing, and rendering power have demonstrated the increasing utility of immersive technology in medicine and the healthcare environment. There are a growing number of publications on using immersive technology in cardiology. We reviewed the articles published within the last decade that reported case studies or research that uses or investigates the application of immersive technology in the broad field of cardiology - from education to preoperative planning and intraoperative guidance. We summarized the advantages and disadvantages of using AR and VR for various application categories. Our review highlights the need for a robust assessment of the effectiveness of the methods and discusses the technical limitations that hinder the complete integration of AR and VR in cardiology, including cost-effectiveness and regulatory compliance. Despite the limitations and gaps that have inhibited us from benefiting from immersive technologies' full potential in cardiology settings to date, its promising, impactful future for standard cardiovascular care is undoubted.

Extended and augmented reality in vascular surgery: Opportunities and challenges

Extended reality has brought new opportunities for medical imaging visualization and analysis. It regroups various subfields, including virtual reality, augmented reality, and mixed reality. Various applications have been proposed for surgical practice, as well as education and training. The aim of this review was to summarize current applications of extended reality and augmented reality in vascular surgery, highlighting potential benefits, pitfalls, limitations, and perspectives on improvement.

Feasibility, Accuracy, and Reproducibility of Aortic Valve Sizing for Transcatheter Aortic Valve Implantation Using Virtual Reality

BACKGROUND

Detailed visualization and precise measurements of aortic valve dimensions are critical for the success of transcatheter aortic valve implantation and for the prevention of complications. Currently, multislice computed tomography is the gold standard for assessment of the aortic annulus and surrounding structures to determine the prosthesis size. New technologies such as virtual reality (VR) not only enable 3-dimensional (3D) visualization with the potential to improve understanding of anatomy and pathology but also allow measurements in 3D. This study aims to investigate the feasibility, accuracy, and reproducibility of VR for the visualization of the aortic valve, the surrounding structures, and its role in preprocedural sizing for transcatheter aortic valve implantation.

METHODS AND RESULTS

Based on the preprocedural multislice computed tomography data, 3mensio measurements and 3D visualizations and measurements using VR software were performed retrospectively on 60 consecutive patients who underwent transcatheter aortic valve implantation at our heart center. There were no significant differences but strong correlations between the VR measurements compared with those performed with the 3mensio software. Furthermore, excellent or good intra- and interobserver reliability could be demonstrated for all values. In a structured questionnaire, users reported that VR simplified anatomical understanding, improved 3D comprehension of adjacent structures, and was associated with very good self-perceived depth perception.

CONCLUSIONS

The use of VR for preprocedural transcatheter aortic valve implantation sizing is feasible and has precise and reproducible measurements. In addition, 3D visualization improves anatomical understanding and orientation. To evaluate the potential benefits of 3D visualization for planning further cardiovascular interventions, research in this field is needed.

Managing Iatrogenic Aortic Dissection: Insight From 3D Holographic Imaging and CT Computational Fluid Dynamic Simulations

Iatrogenic aortic dissection is a rare but life-threatening complication of coronary artery bypass surgery. We report a case with incidentally detected iatrogenic aortic dissection related to aorta cross-clamping that was successfully managed with watchful follow-up. The decision making was based on 3-dimensional holographic and fluid dynamic analysis guidance.

Exploring Augmented Reality Integration in Diagnostic Imaging: Myth or Reality?

This study delves into the transformative potential of integrating augmented reality (AR) within imaging technologies, shedding light on this evolving landscape. Through a comprehensive narrative review, this research uncovers a wealth of literature exploring the intersection between AR and medical imaging, highlighting its growing prominence in healthcare. AR's integration offers a host of potential opportunities to enhance surgical precision, bolster patient engagement, and customize medical interventions. Moreover, when combined with technologies like virtual reality (VR), artificial intelligence (AI), and robotics, AR opens up new avenues for innovation in clinical practice, education, and training. However, amidst these promising prospects lie numerous unanswered questions and areas ripe for exploration. This study emphasizes the need for rigorous research to elucidate the clinical efficacy of AR-integrated interventions, optimize surgical workflows, and address technological challenges. As the healthcare landscape continues to evolve, sustained research efforts are crucial to fully realizing AR's transformative impact in medical imaging. Systematic reviews on AR in healthcare also overlook regulatory and developmental factors, particularly in regard to medical devices. These include compliance with standards, safety regulations, risk management, clinical validation, and developmental processes. Addressing these aspects will provide a comprehensive understanding of the challenges and opportunities in integrating AR into clinical settings, informing stakeholders about crucial regulatory and developmental considerations for successful implementation. Moreover, navigating the regulatory approval process requires substantial financial resources and expertise, presenting barriers to entry for smaller innovators. Collaboration across disciplines and concerted efforts to overcome barriers will be essential in navigating this frontier and harnessing the potential of AR to revolutionize healthcare delivery.

Evolution of Telehealth-Its Impact on Palliative Care and Medication Management

Palliative care plays a crucial role in enhancing the quality of life for individuals facing serious illnesses, aiming to alleviate suffering and provide holistic support. With the advent of telehealth, there is a growing interest in leveraging technology to extend the reach and effectiveness of palliative care services. This article provides a comprehensive review of the evolution of telehealth, the current state of telemedicine in palliative care, and the role of telepharmacy and medication management. Herein we highlight the potential benefits, challenges, and future directions of palliative telemedicine. As the field continues to advance, the article proposes key considerations for future research, policy development, and clinical implementation, aiming to maximize the advantages of telehealth in assisting individuals and their families throughout the palliative care journey. The comprehensive analysis presented herein contributes to a deeper understanding of the role of telehealth in palliative care and serves as a guide for shaping its future trajectory.

A comparison of conventional and advanced 3D imaging techniques for percutaneous left atrial appendage closure

Background

Understanding complex cardiac anatomy is essential for percutaneous left atrial appendage (LAA) closure. Conventional multi-slice computed tomography (MSCT) and transesophageal echocardiography (TEE) are now supported by advanced 3D printing and virtual reality (VR) techniques for three-dimensional visualization of volumetric data sets. This study aimed to investigate their added value for LAA closure procedures.

Methods

Ten patients scheduled for interventional LAA closure were evaluated with MSCT and TEE. Patient-specific 3D printings and VR models were fabricated based on MSCT data. Ten cardiologists then comparatively assessed LAA anatomy and its procedure relevant surrounding structures with all four imaging modalities and rated their procedural utility on a 5-point Likert scale questionnaire (from 1 = strongly agree to 5 = strongly disagree).

Results

Device sizing was rated highest in MSCT (MSCT: 1.9 ± 0.8; TEE: 2.6 ± 0.9; 3D printing: 2.5 ± 1.0; VR: 2.5 ± 1.1; p < 0.01); TEE, VR, and 3D printing were superior in the visualization of the Fossa ovalis compared to MSCT (MSCT: 3.3 ± 1.4; TEE: 2.2 ± 1.3; 3D printing: 2.2 ± 1.4; VR: 1.9 ± 1.3; all p < 0.01). The major strength of VR and 3D printing techniques was a superior depth perception (VR: 1.6 ± 0.5; 3D printing: 1.8 ± 0.4; TEE: 2.9 ± 0.7; MSCT: 2.6 ± 0.8; p < 0.01). The visualization of extracardiac structures was rated less accurate in TEE than MSCT (TEE: 2.6 ± 0.9; MSCT: 1.9 ± 0.8, p < 0.01). However, 3D printing and VR insufficiently visualized extracardiac structures in the present study.

Conclusion

A true 3D visualization in VR or 3D printing provides an additional value in the evaluation of the LAA for the planning of percutaneous closure. In particular, the superior perception of depth was seen as a strength of a 3D visualization. This may contribute to a better overall understanding of the anatomy. Clinical studies are needed to evaluate whether a more comprehensive understanding through advanced multimodal imaging of patient-specific anatomy using VR may translate into improved procedural outcomes.

Immersive Innovations: Exploring the Diverse Applications of Virtual Reality (VR) in Healthcare

Virtual reality (VR) has experienced a remarkable evolution over recent decades, evolving from its initial applications in specific military domains to becoming a ubiquitous and easily accessible technology. This thorough review delves into the intricate domain of VR within healthcare, seeking to offer a comprehensive understanding of its historical evolution, theoretical foundations, and current adoption status. The examination explores the advantages of VR in enhancing the educational experience for medical students, with a particular focus on skill acquisition and retention. Within this exploration, the review dissects the applications of VR across diverse medical disciplines, highlighting its role in surgical training and anatomy/physiology education. While navigating the expansive landscape of VR, the review addresses challenges related to technology and pedagogy, providing insights into overcoming technical hurdles and seamlessly integrating VR into healthcare practices. Additionally, the review looks ahead to future directions and emerging trends, examining the potential impact of technological advancements and innovative applications in healthcare. This review illuminates the transformative potential of VR as a tool poised to revolutionize healthcare practices.

Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement

Recent years have witnessed exponential growth in cardiac imaging technologies, allowing better visualization of complex cardiac anatomy and improved assessment of physiology. These advances have become increasingly important as more complex surgical and catheter-based procedures are evolving to address the needs of a growing congenital heart disease population. This state-of-the-art review presents advances in echocardiography, cardiac magnetic resonance, cardiac computed tomography, invasive angiography, 3-dimensional modeling, and digital twin technology. The paper also highlights the integration of artificial intelligence with imaging technology. While some techniques are in their infancy and need further refinement, others have found their way into clinical workflow at well-resourced centers. Studies to evaluate the clinical value and cost-effectiveness of these techniques are needed. For techniques that enhance the value of care for congenital heart disease patients, resources will need to be allocated for education and training to promote widespread implementation.

Revaiah P, Stanuch M, Skalski A, Onuma Y, Serruys PW. Feasibility and accuracy of real-time 3D-holographic graft length measurements

Aims

Mixed reality (MR) holograms can display high-definition images while preserving the user's situational awareness. New MR software can measure 3D objects with gestures and voice commands; however, these measurements have not been validated. We aimed to assess the feasibility and accuracy of using 3D holograms for measuring the length of coronary artery bypass grafts.

Methods and results

An independent core lab analyzed follow-up computer tomography coronary angiograms performed 30 days after coronary artery bypass grafting in 30 consecutive cases enrolled in the FASTTRACK CABG trial. Two analysts, blinded to clinical information, performed holographic reconstruction and measurements using the CarnaLife Holo software (Medapp, Krakow, Poland). Inter-observer agreement was assessed in the first 20 cases. Another analyst performed the validation measurements using the CardIQ W8 CT system (GE Healthcare, Milwaukee, Wisconsin). Seventy grafts (30 left internal mammary artery grafts, 31 saphenous vein grafts, and 9 right internal mammary artery grafts) were measured. Holographic measurements were feasible in 97.1% of grafts and took 3 minutes 36 s ± 50.74 s per case. There was an excellent inter-observer agreement [interclass correlation coefficient (ICC) 0.99 (0.97-0.99)]. There was no significant difference between the total graft length on hologram and CT [187.5 mm (157.7-211.4) vs. 183.1 mm (156.8-206.1), P = 0.50], respectively. Hologram and CT measurements are highly correlated (r = 0.97, P < 0.001) with an excellent agreement [ICC 0.98 (0.97-0.99)].

Conclusion

Real-time holographic measurements are feasible, quick, and accurate even for tortuous bypass grafts. This new methodology can empower clinicians to visualize and measure 3D images by themselves and may provide insights for procedural strategy.

Computational Biomechanics of Sleep: A Systematic Mapping Review

Biomechanical studies play an important role in understanding the pathophysiology of sleep disorders and providing insights to maintain sleep health. Computational methods facilitate a versatile platform to analyze various biomechanical factors in silico, which would otherwise be difficult through in vivo experiments. The objective of this review is to examine and map the applications of computational biomechanics to sleep-related research topics, including sleep medicine and sleep ergonomics. A systematic search was conducted on PubMed, Scopus, and Web of Science. Research gaps were identified through data synthesis on variants, outcomes, and highlighted features, as well as evidence maps on basic modeling considerations and modeling components of the eligible studies. Twenty-seven studies (n = 27) were categorized into sleep ergonomics (n = 2 on pillow; n = 3 on mattress), sleep-related breathing disorders (n = 19 on obstructive sleep apnea), and sleep-related movement disorders (n = 3 on sleep bruxism). The effects of pillow height and mattress stiffness on spinal curvature were explored. Stress on the temporomandibular joint, and therefore its disorder, was the primary focus of investigations on sleep bruxism. Using finite element morphometry and fluid-structure interaction, studies on obstructive sleep apnea investigated the effects of anatomical variations, muscle activation of the tongue and soft palate, and gravitational direction on the collapse and blockade of the upper airway, in addition to the airflow pressure distribution. Model validation has been one of the greatest hurdles, while single-subject design and surrogate techniques have led to concerns about external validity. Future research might endeavor to reconstruct patient-specific models with patient-specific loading profiles in a larger cohort. Studies on sleep ergonomics research may pave the way for determining ideal spine curvature, in addition to simulating side-lying sleep postures. Sleep bruxism studies may analyze the accumulated dental damage and wear. Research on OSA treatments using computational approaches warrants further investigation.