Virtual and Augmented Reality Techniques for Minimally Invasive Cardiac Interventions: Concept, Design, Evaluation and Pre-clinical Implementation

While less invasive techniques have been employed for some procedures, most intracardiac interventions are still performed under cardiopulmonary bypass, on the drained, arrested heart. The progress toward off-pump intracardiac interventions has been hampered by the lack of adequate visualization inside the beating heart. This thesis describes the development, assessment, and pre-clinical implementation of a mixed reality environment that integrates pre-operative imaging and modeling with surgical tracking technologies and real-time ultrasound imaging. The intra-operative echo images are augmented with pre-operative representations of the cardiac anatomy and virtual models of the delivery instruments tracked in real time using magnetic tracking technologies. As a result, the otherwise context-less images can now be interpreted within the anatomical context provided by the anatomical models. The virtual models assist the user with the tool-to-target navigation, while real-time ultrasound ensures accurate positioning of the tool on target, providing the surgeon with sufficient information to ``see\u27\u27 and manipulate instruments in absence of direct vision. Several pre-clinical acute evaluation studies have been conducted in vivo on swine models to assess the feasibility of the proposed environment in a clinical context. Following direct access inside the beating heart using the UCI, the proposed mixed reality environment was used to provide the necessary visualization and navigation to position a prosthetic mitral valve on the the native annulus, or to place a repair patch on a created septal defect in vivo in porcine models. Following further development and seamless integration into the clinical workflow, we hope that the proposed mixed reality guidance environment may become a significant milestone toward enabling minimally invasive therapy on the beating heart

REAL-TIME 4D ULTRASOUND RECONSTRUCTION FOR IMAGE-GUIDED INTRACARDIAC INTERVENTIONS

Image-guided therapy addresses the lack of direct vision associated with minimally- invasive interventions performed on the beating heart, but requires effective intraoperative imaging. Gated 4D ultrasound reconstruction using a tracked 2D probe generates a time-series of 3D images representing the beating heart over the cardiac cycle. These images have a relatively high spatial resolution and wide field of view, and ultrasound is easily integrated into the intraoperative environment. This thesis presents a real-time 4D ultrasound reconstruction system incorporated within an augmented reality environment for surgical guidance, whose incremental visualization reduces common acquisition errors. The resulting 4D ultrasound datasets are intended for visualization or registration to preoperative images. A human factors experiment demonstrates the advantages of real-time ultrasound reconstruction, and accuracy assessments performed both with a dynamic phantom and intraoperatively reveal RMS localization errors of 2.5-2.7 mm, and 0.8 mm, respectively. Finally, clinical applicability is demonstrated by both porcine and patient imaging

Imaging in electrophysiology

Imaging is becoming increasingly important in clinical cardiac electrophysiology. This article attempts to give a brief overview of what modalities we are presently using, those which may become important, and for what indications we may use them. In addition I will try and convince you why we should use some of them and what data is available concerning some of their potential advantages and drawbacks

3D/2D Registration of Mapping Catheter Images for Arrhythmia Interventional Assistance

Radiofrequency (RF) catheter ablation has transformed treatment for tachyarrhythmias and has become first-line therapy for some tachycardias. The precise localization of the arrhythmogenic site and the positioning of the RF catheter over that site are problematic: they can impair the efficiency of the procedure and are time consuming (several hours). Electroanatomic mapping technologies are available that enable the display of the cardiac chambers and the relative position of ablation lesions. However, these are expensive and use custom-made catheters. The proposed methodology makes use of standard catheters and inexpensive technology in order to create a 3D volume of the heart chamber affected by the arrhythmia. Further, we propose a novel method that uses a priori 3D information of the mapping catheter in order to estimate the 3D locations of multiple electrodes across single view C-arm images. The monoplane algorithm is tested for feasibility on computer simulations and initial canine data.Comment: International Journal of Computer Science Issues, IJCSI, Volume 4, Issue 2, pp10-19, September 200

Thérapies ultrasonores cardiaques guidées par élastographie et échographie ultrarapides

Atrial fibrillation (AF) affects 2-3% of the European and North-American population, whereas ventricular tachyarrhythmia (VT) is related to an important risk of sudden death. AF and VT originate from dysfunctional electrical activity in cardiac tissues. Minimally-invasive approaches such as Radio-Frequency Catheter Ablation (RFCA) have revolutionized the treatment of these diseases; however the success rate of RFCA is currently limited by the lack of monitoring techniques to precisely control the extent of thermally ablated tissue.The aim of this thesis is to propose novel ultrasound-based approaches for minimally invasive cardiac ablation under guidance of ultrasound imaging. For this, first, we validated the accuracy and clinical viability of Shear-Wave Elastography (SWE) as a real-time quantitative imaging modality for thermal ablation monitoring in vivo. Second we implemented SWE on an intracardiac transducer and validated the feasibility of evaluating thermal ablation in vitro and in vivo on beating hearts of a large animal model. Third, a dual-mode intracardiac transducer was developed to perform both ultrasound therapy and imaging with the same elements, on the same device. SWE-controlled High-Intensity-Focused-Ultrasound thermal lesions were successfully performed in vivo in the atria and the ventricles of a large animal model. At last, SWE was implemented on a transesophageal ultrasound imaging and therapy device and the feasibility of transesophageal approach was demonstrated in vitro and in vivo. These novel approaches may lead to new clinical devices for a safer and controlled treatment of a wide variety of cardiac arrhythmias and diseases.La fibrillation atriale affecte 2-3% des européens et nord-américains, les tachycardies ventriculaires sont liées à un risque important de mort subite. Les approches minimalement invasives comme l’Ablation par Cathéter Radiofréquence (RFCA) ont révolutionné le traitement de ces maladies, mais le taux de réussite de la RFCA est limité par le manque de techniques d’imagerie pour contrôler cette ablation thermique.Le but de cette thèse est de proposer de nouvelles approches ultrasonores pour des traitements cardiaques minimalement invasifs guidés par échographie.Pour cela nous avons d’abord validé la précision et la viabilité clinique de l’Élastographie par Ondes de Cisaillement (SWE) en tant que modalité d’imagerie quantitative et temps réel pour l’ablation thermique in vivo. Ensuite nous avons implémenté la SWE sur un transducteur intracardiaque et validé la faisabilité d’évaluer l’ablation thermique in vitro et in vivo sur cœur battant de gros animal. Puis nous avons développé un transducteur intracardiaque dual-mode pour effectuer l’ablation et l’imagerie ultrasonores avec les mêmes éléments, sur le même dispositif. Les lésions thermiques induites par Ultrasons Focalisés de Haute Intensité (HIFU) et contrôlées par la SWE ont été réalisées avec succès in vivo dans les oreillettes et les ventricules chez le gros animal. Finalement la SWE a été implémentée sur un dispositif d’imagerie et thérapie ultrasonores transœsophagien et la faisabilité de cette approche a été démontrée in vitro et in vivo. Ces approches originales pourraient conduire à de nouveaux dispositifs cliniques pour des traitements plus sûrs et contrôlés d’un large éventail d’arythmies et maladies cardiaques

Intracardiac Ultrasound Guided Systems for Transcatheter Cardiac Interventions

Transcatheter cardiac interventions are characterized by their percutaneous nature, increased patient safety, and low hospitalization times. Transcatheter procedures involve two major stages: navigation towards the target site and the positioning of tools to deliver the therapy, during which the interventionalists face the challenge of visualizing the anatomy and the relative position of the tools such as a guidewire. Fluoroscopic and transesophageal ultrasound (TEE) imaging are the most used techniques in cardiac procedures; however, they possess the disadvantage of radiation exposure and suboptimal imaging. This work explores the potential of intracardiac ultrasound (ICE) within an image guidance system (IGS) to facilitate the two stages of cardiac interventions. First, a novel 2.5D side-firing, conical Foresight ICE probe (Conavi Medical Inc., Toronto) is characterized, calibrated, and tracked using an electromagnetic sensor. The results indicate an acceptable tracking accuracy within some limitations. Next, an IGS is developed for navigating the vessels without fluoroscopy. A forward-looking, tracked ICE probe is used to reconstruct the vessel on a phantom which mimics the ultrasound imaging of an animal vena cava. Deep learning methods are employed to segment the complex vessel geometry from ICE imaging for the first time. The ICE-reconstructed vessel showed a clinically acceptable range of accuracy. Finally, a guidance system was developed to facilitate the positioning of tools during a tricuspid valve repair. The designed system potentially facilitates the positioning of the TriClip at the coaptation gap by pre-mapping the corresponding site of regurgitation in 3D tracking space