Using needle orientation sensing as surrogate signal for respiratory motion estimation in percutaneous interventions

Purpose To develop and evaluate an approach to estimate the respiratory-induced motion of lesions in the chest and abdomen. Materials and methods The proposed approach uses the motion of an initial reference needle inserted into a moving organ to estimate the lesion (target) displacement that is caused by respiration. The needles position is measured using an inertial measurement unit (IMU) sensor externally attached to the hub of an initially placed reference needle. Data obtained from the IMU sensor and the target motion are used to train a learning-based approach to estimate the position of the moving target. An experimental platform was designed to mimic respiratory motion of the liver. Liver motion profiles of human subjects provided inputs to the experimental platform. Variables including the insertion angle, target depth, target motion velocity and target proximity to the reference needle were evaluated by measuring the error of the estimated target position and processing time. Results: The mean error of estimation of the target position ranged between 0.86 and 1.29 mm. The processing maximum training and testing time was 5 ms which is suitable for real-time target motion estimation using the needle position sensor. Conclusion: The external motion of an initially placed reference needle inserted into a moving organ can be used as a surrogate, measurable and accessible signal to estimate in real-time the position of a moving target caused by respiration; this technique could then be used to guide the placement of subsequently inserted needles directly into the target

Real-Time Magnetic Resonance Imaging

Real‐time magnetic resonance imaging (RT‐MRI) allows for imaging dynamic processes as they occur, without relying on any repetition or synchronization. This is made possible by modern MRI technology such as fast‐switching gradients and parallel imaging. It is compatible with many (but not all) MRI sequences, including spoiled gradient echo, balanced steady‐state free precession, and single‐shot rapid acquisition with relaxation enhancement. RT‐MRI has earned an important role in both diagnostic imaging and image guidance of invasive procedures. Its unique diagnostic value is prominent in areas of the body that undergo substantial and often irregular motion, such as the heart, gastrointestinal system, upper airway vocal tract, and joints. Its value in interventional procedure guidance is prominent for procedures that require multiple forms of soft‐tissue contrast, as well as flow information. In this review, we discuss the history of RT‐MRI, fundamental tradeoffs, enabling technology, established applications, and current trends

Cardiac magnetic resonance assessment of central and peripheral vascular function in patients undergoing renal sympathetic denervation as predictor for blood pressure response

Background: Most trials regarding catheter-based renal sympathetic denervation (RDN) describe a proportion of patients without blood pressure response. Recently, we were able to show arterial stiffness, measured by invasive pulse wave velocity (IPWV), seems to be an excellent predictor for blood pressure response. However, given the invasiveness, IPWV is less suitable as a selection criterion for patients undergoing RDN. Consequently, we aimed to investigate the value of cardiac magnetic resonance (CMR) based measures of arterial stiffness in predicting the outcome of RDN compared to IPWV as reference. Methods: Patients underwent CMR prior to RDN to assess ascending aortic distensibility (AAD), total arterial compliance (TAC), and systemic vascular resistance (SVR). In a second step, central aortic blood pressure was estimated from ascending aortic area change and flow sequences and used to re-calculate total arterial compliance (cTAC). Additionally, IPWV was acquired. Results: Thirty-two patients (24 responders and 8 non-responders) were available for analysis. AAD, TAC and cTAC were higher in responders, IPWV was higher in non-responders. SVR was not different between the groups. Patients with AAD, cTAC or TAC above median and IPWV below median had significantly better BP response. Receiver operating characteristic (ROC) curves predicting blood pressure response for IPWV, AAD, cTAC and TAC revealed areas under the curve of 0.849, 0.828, 0.776 and 0.753 (p = 0.004, 0.006, 0.021 and 0.035). Conclusions: Beyond IPWV, AAD, cTAC and TAC appear as useful outcome predictors for RDN in patients with hypertension. CMR-derived markers of arterial stiffness might serve as non-invasive selection criteria for RDN

Remote Navigation and Contact-Force Control of Radiofrequency Ablation Catheters

Atrial fibrillation (AF), the most common and clinically significant heart rhythm disorder, is characterized by rapid and irregular electrical activity in the upper chambers resulting in abnormal contractions. Radiofrequency (RF) cardiac catheter ablation is a minimally invasive curative treatment that aims to electrically correct signal pathways inside the atria to restore normal sinus rhythm. Successful catheter ablation requires the complete and permanent elimination of arrhythmogenic signals by delivering transmural RF ablation lesions contiguously near and around key cardiac structures. These procedures are complex and technically challenging and, even when performed by the most skilled physician, nearly half of patients undergo repeat procedures due to incomplete elimination of the arrhythmogenic pathways. This thesis aims to incorporate innovative design to improve catheter stability and maneuverability through the development of robotic platforms that enable precise placement of reproducibly durable ablation lesions. The first part of this thesis deals with the challenges to lesion delivery imposed by cardiorespiratory motion. One of the main determinants of the delivery of durable and transmural RF lesions is the ability to define and maintain a constant contact force between the catheter tip electrode and cardiac tissue, which is hampered by the presence of cardiorespiratory motion. To address this need, I developed and evaluated a novel catheter contact-force control device. The compact electromechanical add-on tool monitors catheter-tissue contact force in real-time and simultaneously adjusts the position of a force-sensing ablation catheter within a steerable sheath to compensate for the change in contact force. In a series of in vitro and in vivo experiments, the contact-force control device demonstrated an ability to: a) maintain an average force to within 1 gram of a set level; b) reduce contact-force variation to below 5 grams (2-8-fold improvement over manual catheter intervention); c) ensure the catheter tip never lost contact with the tissue and never approached dangerous force levels; and importantly, d) deliver reproducible RF ablation lesions regardless of cardiac tissue motion, which were of the same depth and volume as lesions delivered in the absence of tissue motion. In the second part of the thesis, I describe a novel steerable sheath and catheter robotic navigation system, which incorporates the catheter contact-force controller. The robotic platform enables precise and accurate manipulation of a remote conventional steerable sheath and permits catheter-tissue contact-force control. The robotic navigation system was evaluated in vitro using a phantom that combines stationary and moving targets within an in vitro model representing a beating heart. An electrophysiologist used the robotic system to remotely navigate the sheath and catheter tip to select targets and compared the accuracy of reaching these targets performing the same tasks manually. Robotic intervention resulted in significantly higher accuracy and significantly improved the contact-force profile between the catheter tip and moving tissue-mimicking material. Our studies demonstrate that using available contact-force information within a robotic system can ensure precise and accurate placement of reliably transmural RF ablation lesions. These robotic systems can be valuable tools used to optimize RF lesion delivery techniques and ultimately improve clinical outcomes for AF ablation therapy

The Role of Visualization, Force Feedback, and Augmented Reality in Minimally Invasive Heart Valve Repair

New cardiovascular techniques have been developed to address the unique requirements of high risk, elderly, surgical patients with heart valve disease by avoiding both sternotomy and cardiopulmonary bypass. However, these technologies pose new challenges in visualization, force application, and intracardiac navigation. Force feedback and augmented reality (AR) can be applied to minimally invasive mitral valve repair and transcatheter aortic valve implantation (TAVI) techniques to potentially surmount these challenges. Our study demonstrated shorter operative times with three dimensional (3D) visualization compared to two dimensional (2D) visualization; however, both experts and novices applied significantly more force to cardiac tissue during 3D robotics-assisted mitral valve annuloplasty than during conventional open mitral valve annuloplasty. This finding suggests that 3D visualization does not fully compensate for the absence of haptic feedback in robotics-assisted cardiac surgery. Subsequently, using an innovative robotics-assisted surgical system design, we determined that direct haptic feedback may improve both expert and trainee performance using robotics-assisted techniques. We determined that during robotics-assisted mitral valve annuloplasty the use of either visual or direct force feedback resulted in a significant decrease in forces applied to cardiac tissue when compared to robotics-assisted mitral valve annuloplasty without force feedback. We presented NeoNav, an AR-enhanced echocardiograpy intracardiac guidance system for NeoChord off-pump mitral valve repair. Our study demonstrated superior tool navigation accuracy, significantly shorter navigation times, and reduced potential for injury with AR enhanced intracardiac navigation for off-pump transapical mitral valve repair with neochordae implantation. In addition, we applied the NeoNav system as a safe and inexpensive alternative imaging modality for TAVI guidance. We found that our proposed AR guidance system may achieve similar or better results than the current standard of care, contrast enhanced fluoroscopy, while eliminating the use of nephrotoxic contrast and ionizing radiation. These results suggest that the addition of both force feedback and augmented reality image guidance can improve both surgical performance and safety during minimally invasive robotics assisted and beating heart valve surgery, respectively

Development of an image guidance system for laparoscopic liver surgery and evaluation of optical and computer vision techniques for the assessment of liver tissue

Introduction: Liver resection is increasingly being carried out via the laparoscopic approach (keyhole surgery) because there is mounting evidence that it benefits patients by reducing pain and length of hospitalisation. There are however ongoing concerns about oncological radicality (i.e. ability to completely remove cancer) and an inability to control massive haemorrhage. These issues can partially be attributed to a loss of sensation such as depth perception, tactile feedback and a reduced field of view. Utilisation of optical imaging and computer vision may be able to compensate for some of the lost sensory input because these modalities can facilitate visualisation of liver tissue and structural anatomy. Their use in laparoscopy is attractive because it is easy to adapt or integrate with existing technology. The aim of this thesis is to explore to what extent this technology can aid in the detection of normal and abnormal liver tissue and structures. / Methods: The current state of the art for optical imaging and computer vision in laparoscopic liver surgery is assessed in a systematic review. Evaluation of confocal laser endomicroscopy is carried out on a murine and porcine model of liver disease. Multispectral near infrared imaging is evaluated on ex-vivo liver specimen. Video magnification is assessed on a mechanical flow phantom and a porcine model of liver disease. The latter model was also employed to develop a computer vision based image guidance system for laparoscopic liver surgery. This image guidance system is further evaluated in a clinical feasibility study. Where appropriate, experimental findings are substantiated with statistical analysis. / Results: Use of confocal laser endomicroscopy enabled discrimination between cancer and normal liver tissue with a sub-millimetre precision. This technology also made it possible to verify the adequacy of thermal liver ablation. Multispectral imaging, at specific wavelengths was shown to have the potential to highlight the presence of colorectal and hepatocellular cancer. An image reprocessing algorithm is proposed to simplify visual interpretation of the resulting images. It is shown that video magnification can determine the presence of pulsatile motion but that it cannot reliably determine the extent of motion. Development and performance metrics of an image guidance system for laparoscopic liver surgery are outlined. The system was found to improve intraoperative orientation more development work is however required to enable reliable prediction of oncological margins. / Discussion: The results in this thesis indicate that confocal laser endomicroscopy and image guidance systems have reached a development stage where their intraoperative use may benefit surgeons by visualising features of liver anatomy and tissue characteristics. Video magnification and multispectral imaging require more development and suggestions are made to direct this work. It is also highlighted that it is crucial to standardise assessment methods for these technologies which will allow a more direct comparison between the outcomes of different groups. Limited imaging depth is a major restriction of these technologies but this may be overcome by combining them with preoperatively obtained imaging data. Just like laparoscopy, optical imaging and computer vision use functions of light, a shared characteristic that makes their combined use complementary

Virtual Reality Aided Mobile C-arm Positioning for Image-Guided Surgery

Image-guided surgery (IGS) is the minimally invasive procedure based on the pre-operative volume in conjunction with intra-operative X-ray images which are commonly captured by mobile C-arms for the confirmation of surgical outcomes. Although currently some commercial navigation systems are employed, one critical issue of such systems is the neglect regarding the radiation exposure to the patient and surgeons. In practice, when one surgical stage is finished, several X-ray images have to be acquired repeatedly by the mobile C-arm to obtain the desired image. Excessive radiation exposure may increase the risk of some complications. Therefore, it is necessary to develop a positioning system for mobile C-arms, and achieve one-time imaging to avoid the additional radiation exposure. In this dissertation, a mobile C-arm positioning system is proposed with the aid of virtual reality (VR). The surface model of patient is reconstructed by a camera mounted on the mobile C-arm. A novel registration method is proposed to align this model and pre-operative volume based on a tracker, so that surgeons can visualize the hidden anatomy directly from the outside view and determine a reference pose of C-arm. Considering the congested operating room, the C-arm is modeled as manipulator with a movable base to maneuver the image intensifier to the desired pose. In the registration procedure above, intensity-based 2D/3D registration is used to transform the pre-operative volume into the coordinate system of tracker. Although it provides a high accuracy, the small capture range hinders its clinical use due to the initial guess. To address such problem, a robust and fast initialization method is proposed based on the automatic tracking based initialization and multi-resolution estimation in frequency domain. This hardware-software integrated approach provides almost optimal transformation parameters for intensity-based registration. To determine the pose of mobile C-arm, high-quality visualization is necessary to locate the pathology in the hidden anatomy. A novel dimensionality reduction method based on sparse representation is proposed for the design of multi-dimensional transfer function in direct volume rendering. It not only achieves the similar performance to the conventional methods, but also owns the capability to deal with the large data sets