Preparing for the future of cardiothoracic surgery with virtual reality simulation and surgical planning:a narrative review

Background and Objective: Virtual reality (VR) technology in cardiothoracic surgery has been an area of interest for almost three decades, but computational limitations had restricted its implementation. Recent advances in computing power have facilitated the creation of high-fidelity VR simulations and anatomy visualisation tools. We undertook a non-systematic narrative review of literature on VR simulations and preoperative planning tools in cardiothoracic surgery and present the state-of-the-art, and a future outlook. Methods: A comprehensive search through MEDLINE database was performed in November 2022 for all publications that describe the use of VR in cardiothoracic surgery regarding training purposes, education, simulation, and procedural planning. We excluded papers that were not in English or Dutch, and that used two-dimensional (2D) screens, augmented, and simulated reality. Key Content and Findings: Results were categorised as simulators and preoperative planning tools. Current surgical simulators include the lobectomy module in the LapSim for video assisted thorascopic surgery which has been extensively validated, and the more recent robotic assisted lobectomy simulators from Robotix Mentor and Da Vinci SimNow, which are increasingly becoming integrated into the robotic surgery curriculum. Other perioperative simulators include the CardioPulmonary VR Resuscitation simulator for advanced life support after cardiac surgery, and the VR Extracorporeal Circulation (ECC) simulator for perfusionists to simulate the use of a heart-lung machine (HLM). For surgical planning, there are many small-scale tools available, and many case/pilot studies have been published utilising the visualisation possibilities provided by VR, including congenital cardiac, congenital thoracic, adult cardiac, and adult thoracic diseases. Conclusions: There are many promising tools becoming available to leverage the immersive power of VR in cardiothoracic surgery. The path to validate these simulators is well described, but large-scale trials producing high-level evidence for their efficacy are absent as of yet. Our view is that these tools will become increasingly integral parts of daily practice in this field in the coming decade.</p

Optimized Preoperative Planning of Double Outlet Right Ventricle Patients by 3D Printing and Virtual Reality:A Pilot Study

OBJECTIVES: In complex double outlet right ventricle (DORV) patients, the optimal surgical approach may be difficult to assess based on conventional two-dimensional (2D) ultrasound (US) and computed tomography (CT) imaging. The aim of this study is to assess the added value of 3D printed and 3D Virtual Reality (VR) models of the heart used for surgical planning in DORV patients, supplementary to the gold standard 2D imaging modalities.METHODS: Five patients with different DORV-subtypes and high-quality CT scans were selected retrospectively. 3D prints and 3D-VR models were created. Twelve congenital cardiac surgeons and paediatric cardiologists, from three different hospitals, were shown 2D-CT first, after which they assessed the 3D print and 3D-VR models in random order. After each imaging method, a questionnaire was filled in on the visibility of essential structures and the surgical plan.RESULTS: Spatial relationships were generally better visualized using 3D methods (3D printing/3D-VR) than in 2D. The feasibility of VSD patch closure could be determined best using 3D-VR reconstructions (3D-VR 92%, 3D print 66%, and US/CT 46%, P &lt; 0.01). The percentage of proposed surgical plans corresponding to the performed surgical approach was 66% for plans based on US/CT, 78% for plans based on 3D printing, and 80% for plans based on 3D-VR visualization.CONCLUSIONS: This study shows that both 3D printing and 3D-VR have additional value for cardiac surgeons and cardiologists over 2D imaging, because of better visualization of spatial relationships. As a result, the proposed surgical plans based on the 3D visualizations matched the actual performed surgery to a greater extent.</p

Essential Surgical Plan Modifications After Virtual Reality Planning in 50 Consecutive Segmentectomies

Background: Lately, increased interest in pulmonary segmentectomy has been observed. Segmental border identification is extremely difficult on 2-dimensional computed tomography (CT). Preoperative application of virtual reality (VR) can provide better insight into patient-specific anatomy. The aim of this study was to investigate the added clinical value of 3-dimensional (3D) VR using PulmoVR for preoperative planning. Methods: Patients with an indication for pulmonary segmentectomy were included between June 2020 and September 2021 at the Erasmus Medical Center, Rotterdam, The Netherlands. CT scans were (semi)automatically segmented to visualize lung segments, segmental arteries, veins, and bronchi. Three surgeons made a surgical plan on the basis of the conventional CT scan and subsequently analyzed the VR visualization. The primary outcome was the incidence of critical (ensuring radical resection) preoperative plan modifications. Secondarily, data on observed anatomic variation and perioperative (oncologic) outcomes were collected. Results: A total of 50 patients (median age at surgery, 65 years [interquartile range, 17.25 years]) with an indication for pulmonary segmentectomy were included. After supplemental VR visualization, the surgical plan was adjusted in 52%; the tumor was localized in a different segment in 14%, more lung-sparing resection was planned in 10%, and extended segmentectomy, including 1 lobectomy, was planned in 28%. Pathologic examination confirmed radical resection in 49 patients (98%). Conclusions: This 3D VR technology showed added clinical value in the first 50 VR-guided segmentectomies because a 52% change of plan with 98% radical resection was observed. Furthermore, 3D VR visualization of the bronchovasculature, including various anatomic variations, provided better insight into patient-specific anatomy and offered lung-sparing possibilities with more certainty

Virtual Reality Simulator versus Conventional Advanced Life Support Training for Cardiopulmonary Resuscitation Post-Cardiac Surgery: A Randomized Controlled Trial

External chest compressions are often ineffective for patients arresting after cardiac surgery, for whom emergency resternotomy may be required. A single-blinded randomized controlled trial (RCT) was performed, with participants being randomized to a virtual reality (VR) Cardiac Surgical Unit Advanced Life Support (CSU-ALS) simulator training arm or a conventional classroom CSU-ALS training arm. Twenty-eight cardiothoracic surgery (CTS) residents were included and subsequently assessed in a moulage scenario in groups of two, either participating as a leader or surgeon. The primary binary outcomes were two time targets: (1) delivering three stacked shocks within 1 min and (2) resternotomy within 5 min. Secondary outcomes were the number of protocol mistakes made and a questionnaire after the VR simulator. The conventional training group administered stacked shocks within 1 min in 43% (n = 6) of cases, and none in the VR group reached this target, missing it by an average of 25 s. The resternotomy time target was reached in 100% of the cases (n = 14) in the conventional training group and in 83% of the cases (n = 10) in the VR group. The VR group made 11 mistakes in total versus 15 for those who underwent conventional training. Participants reported that the VR simulator was useful and easy to use. The results show that the VR simulator can provide adequate CSU-ALS training. Moreover, VR training results in fewer mistakes suggesting that repetitive practice in an immersive environment improves skills

Virtual Reality Simulator versus Conventional Advanced Life Support Training for Cardiopulmonary Resuscitation Post-Cardiac Surgery: A Randomized Controlled Trial

External chest compressions are often ineffective for patients arresting after cardiac surgery, for whom emergency resternotomy may be required. A single-blinded randomized controlled trial (RCT) was performed, with participants being randomized to a virtual reality (VR) Cardiac Surgical Unit Advanced Life Support (CSU-ALS) simulator training arm or a conventional classroom CSU-ALS training arm. Twenty-eight cardiothoracic surgery (CTS) residents were included and subsequently assessed in a moulage scenario in groups of two, either participating as a leader or surgeon. The primary binary outcomes were two time targets: (1) delivering three stacked shocks within 1 min and (2) resternotomy within 5 min. Secondary outcomes were the number of protocol mistakes made and a questionnaire after the VR simulator. The conventional training group administered stacked shocks within 1 min in 43% (n = 6) of cases, and none in the VR group reached this target, missing it by an average of 25 s. The resternotomy time target was reached in 100% of the cases (n = 14) in the conventional training group and in 83% of the cases (n = 10) in the VR group. The VR group made 11 mistakes in total versus 15 for those who underwent conventional training. Participants reported that the VR simulator was useful and easy to use. The results show that the VR simulator can provide adequate CSU-ALS training. Moreover, VR training results in fewer mistakes suggesting that repetitive practice in an immersive environment improves skills

3D Virtual Reality Imaging of Major Aortopulmonary Collateral Arteries: A Novel Diagnostic Modality

Background Major aortopulmonary collateral arteries (MAPCAs), as seen in patients with pulmonary atresia, are arteries that supply blood from the aorta to the lungs and often require surgical intervention. To achieve complete repair in the least number of interventions, optimal imaging of the pulmonary arterial anatomy and MAPCAs is critical. 3D virtual reality (3D-VR) is a promising and upcoming new technology that could potentially ameliorate current imaging shortcomings. Methods A retrospective, proof-of-concept study was performed of all operated patients with pulmonary atresia and MAPCAs at our center between 2010 and 2020 with a preoperative computed tomography (CT) scan. CT images were reviewed by two congenital cardiac surgeons in 3D-VR to determine additional value of VR for MAPCA imaging compared to conventional CT and for preoperative planning of MAPCA repair. Results 3D-VR visualizations were reconstructed from CT scans of seven newborns where the enhanced topographic anatomy resulted in improved visualization of MAPCA. In addition, surgical planning was improved since new observations or different preoperative plans were apparent in 4 out of 7 cases. After the initial setup, VR software and hardware was reported to be easy and intuitive to use. Conclusions This study showed technical feasibility of 3D-VR reconstruction of children with immersive visualization of topographic anatomy in an easy-to-use format leading to an improved surgical planning of MAPCA surgery. Future prospective studies are required to investigate the clinical benefits in larger populations

3D Virtual Reality Imaging of Major Aortopulmonary Collateral Arteries: A Novel Diagnostic Modality

BackgroundMajor aortopulmonary collateral arteries (MAPCAs), as seen in patients with pulmonary atresia, are arteries that supply blood from the aorta to the lungs and often require surgical intervention. To achieve complete repair in the least number of interventions, optimal imaging of the pulmonary arterial anatomy and MAPCAs is critical. 3D virtual reality (3D-VR) is a promising and upcoming new technology that could potentially ameliorate current imaging shortcomings.MethodsA retrospective, proof-of-concept study was performed of all operated patients with pulmonary atresia and MAPCAs at our center between 2010 and 2020 with a preoperative computed tomography (CT) scan. CT images were reviewed by two congenital cardiac surgeons in 3D-VR to determine additional value of VR for MAPCA imaging compared to conventional CT and for preoperative planning of MAPCA repair.Results3D-VR visualizations were reconstructed from CT scans of seven newborns where the enhanced topographic anatomy resulted in improved visualization of MAPCA. In addition, surgical planning was improved since new observations or different preoperative plans were apparent in 4 out of 7 cases. After the initial setup, VR software and hardware was reported to be easy and intuitive to use.ConclusionsThis study showed technical feasibility of 3D-VR reconstruction of children with immersive visualization of topographic anatomy in an easy-to-use format leading to an improved surgical planning of MAPCA surgery. Future prospective studies are required to investigate the clinical benefits in larger populations

Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study

Background: Cardiac arrest after cardiac surgery commonly has a reversible cause, where emergency resternotomy is often required for treatment, as recommended by international guidelines. We have developed a virtual reality (VR) simulation for training of cardiopulmonary resuscitation (CPR) and emergency resternotomy procedures after cardiac surgery, the Cardiopulmonary Resuscitation Virtual Reality Simulator (CPVR-sim). Two fictive clinical scenarios were used: one case of pulseless electrical activity (PEA) and a combined case of PEA and ventricular fibrillation. In this prospective study, we researched the face validity and content validity of the CPVR-sim. Objective: We designed a prospective study to assess the feasibility and to establish the face and content validity of two clinical scenarios (shockable and nonshockable cardiac arrest) of the CPVR-sim partly divided into a group of novices and experts in performing CPR and emergency resternotomies in patients after cardiac surgery. Methods: Clinicians (staff cardiothoracic surgeons, physicians, surgical residents, nurse practitioners, and medical students) participated in this study and performed two different scenarios, either PEA or combined PEA and ventricular fibrillation. All participants (N=41) performed a simulation and completed the questionnaire rating the simulator's usefulness, satisfaction, ease of use, effectiveness, and immersiveness to assess face validity and content validity. Results: Responses toward face validity and content validity were predominantly positive in both groups. Most participants in the PEA scenario (n=26, 87%) felt actively involved in the simulation, and 23 (77%) participants felt in charge of the situation. The participants thought it was easy to learn how to interact with the software (n=24, 80%) and thought that the software responded adequately (n=21, 70%). All 15 (100%) expert participants preferred VR training as an addition to conventional training. Moreover, 13 (87%) of the expert participants would recommend VR training to other colleagues, and 14 (93%) of the expert participants thought the CPVR-sim was a useful method to train for infrequent post-cardiac surgery emergencies requiring CPR. Additionally, 10 (91%) of the participants thought it was easy to move in the VR environment, and that the CPVR-sim responded adequately in this scenario. Conclusions: We developed a proof-of-concept VR simulation for CPR training with two scenarios of a patient after cardiac surgery, which participants found was immersive and useful. By proving the face validity and content validity of the CPVR-sim, we present the first step toward a cardiothoracic surgery VR training platform

Outcomes after right ventricular outflow tract reconstruction with valve substitutes: A systematic review and meta-analysis

Introduction: This study aims to provide an overview of outcomes after right ventricular outflow tract (RVOT) reconstruction using different valve substitutes in different age groups for different indications. Methods: The literature was systematically searched for articles published between January 2000 and June 2021 reporting on clinical and/or echocardiographic outcomes after RVOT reconstruction with valve substitutes. A random-effects meta-analysis was conducted for outcomes, and time-related outcomes were visualized by pooled Kaplan–Meier curves. Subgroup analyses were performed according to etiology, implanted valve substitute and patient age. Results: Two hundred and seventeen articles were included, comprising 37,078 patients (age: 22.86 ± 11.29 years; 31.6% female) and 240,581 patient-years of follow-up. Aortic valve disease (Ross procedure, 46.6%) and Tetralogy of Fallot (TOF, 27.0%) were the two main underlying etiologies. Homograft and xenograft accounted for 83.7 and 32.6% of the overall valve substitutes, respectively. The early mortality, late mortality, reintervention and endocarditis rates were 3.36% (2.91–3.88), 0.72%/y (95% CI: 0.62–0.82), 2.62%/y (95% CI: 2.28–3.00), and 0.38%/y (95%CI: 0.31–0.47) for all patients. The early mortality for TOF and truncus arteriosus (TA) were 1.95% (1.31–2.90) and 10.67% (7.79–14.61). Pooled late mortality and reintervention rate were 0.59%/y (0.39–0.89), 1.41%/y (0.87–2.27), and 1.20%/y (0.74–1.94), 10.15%/y (7.42–13.90) for TOF and TA, respectively. Endocarditis rate was 0.21%/y (95% CI: 0.16–0.27) for a homograft substitute and 0.80%/y (95%CI: 0.60–1.09) for a xenograft substitute. Reintervention rate for infants, children and adults was 8.80%/y (95% CI: 6.49–11.95), 4.75%/y (95% CI: 3.67–6.14), and 0.72%/y (95% CI: 0.36–1.42), respectively. Conclusion: This study shows RVOT reconstruction with valve substitutes can be performed with acceptable mortality and morbidity rates for most patients. Reinterventions after RVOT reconstruction with valve substitutes are inevitable for most patients in their life-time, emphasizing the necessity of life-long follow-up and multidisciplinary care. Follow-up protocols should be tailored to individual patients because patients with different etiologies, ages, and implanted valve substitutes have different rates of mortality and morbidity. Systematic review registration: [www.crd.york.ac.uk/prospero], identifier [CRD42021271622]