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Circ Cardiovasc Imaging. 2019;12:e009297. DOI: 10.1161/CIRCIMAGING.119.009297 July 2019 1
Elena Giulia Milano, MD
Endrit Pajaziti, BEng
Emilie Sauvage, PhD
Andrew Cook, PhD
Silvia Schievano, PhD
Kristian H. Mortensen,
MD, PhD
Andrew M Taylor, MD,
PhD
Jan Marek, MD, PhD
Martin Kostolny, MD
Claudio Capelli, PhD
An 11-month-old patient with a postnatal diagnosis of double outlet right
ventricle (DORV) with side-by-side great arteries, large noncommitted ven-
tricular septal defect (VSD), and a small muscular apical VSD was evaluated
for feasibility of biventricular repair, after a previous palliation with pulmonary ar-
tery banding at age of 14 days. Transthoracic echocardiography showed tricuspid
chordal attachment to the crest of the interventricular septum, a noncommitted
VSD (Figure1), a small additional apical muscular VSD, and moderate flow accel-
eration below the pulmonary valve secondary to double conus. Cardiac computed
tomography (CT) confirmed the presence of significant subpulmonary obstruction
with right ventricular (RV) hypertrophy (Figure2A and 2B). A 3D volume recon-
structed from CT (Figure2C and 2D) was used as an input for a virtual reality (VR)
application, which was setup at our Center (Figure in the Data Supplement).
The VR platform was adopted for the first time by our surgical team during
the planning phase. Intracardiac structures of the patient-specific model were
explored, and the views from the standard surgical access were mimicked (Movie
I in the Data Supplement). This allowed a full estimation of the spatial relationship
between VSD and the great vessels. The VR-based model allowed the surgeons to
simulate an unobstructed baffle path with no interference with the tricuspid valve
apparatus (Figure3A and 3B), in multiple cross-sectional views in 3D.
The patient underwent successful intracardiac biventricular repair with VSD
enlargement, division of mid cavity RV muscle bundles, and an intraventricular
tunneling through the VSD to the aorta. Postoperative imaging showed patent LV
to aorta tunnel (Figure3, Movie II in the Data Supplement) with laminar flow and
no residual VSD.
DORV represents a spectrum of congenital heart defects with a wide range of
anatomic variations, often unique. The DORV anatomic type is known to influence
patient outcomes; with noncommitted VSDs being associated with higher risks of
death, reoperation,1 and late onset of left ventricular outflow tract obstruction.
Intraventricular repair performed with arterial switch is the procedure that carries
the highest risk of early mortality irrespective DORV anatomy.1 Therefore, a careful
multidisciplinary approach is needed.
VR provides a unique experience to interact easily with digital 3D complex
objects, completely immersed within a simulated environment, through the use
of a VR headset, which contains a stereoscopic display and tracking capabilities
via external sensors. Early examples in literature show the use of VR for enhanced
evaluation of VSD2 and in a case of Truncus arteriosus3 as well as for educational
purposes.4
In this specific case, the VR setup allowed the leading surgeon to navigate inside
and interact with the patient-specific model not only from conventional surgical
views but also by approaching the defect from unconventional surgical angles
© 2019 American Heart Association, Inc.
CARDIOVASCULAR IMAGES
Taking Surgery Out of Reality
A Virtual Journey Into Double Outlet Right Ventricle
Circulation: Cardiovascular Imaging
https://www.ahajournals.org/journal/
circimaging
Key Words: anatomic variation
aorta hypertrophy pulmonary
artery surgeons
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Circ Cardiovasc Imaging. 2019;12:e009297. DOI: 10.1161/CIRCIMAGING.119.009297 July 2019 2
Milano et al; Virtual Reality in Congenital Heart Disease
Figure 1. Pre-surgical echocardiography assessment.
A, Two-dimensional subcostal 4-chamber view demonstrating right ventricle (RV) giving rise to right anterior aorta (AO) with pulmonary artery (PA) trunk left and slightly
anterior. B, Color flow mapping confirmed left-to-right shunt across interventricular communication (yellow arrow). C, Echocardiographic 3D reconstruction better
visualized the location and size of ventricular septal defect (VSD; yellow arrow) and considered pathway from the left ventricle (LV) through the VSD towards aorta.
Figure 2. Comparison between computed tomography (CT) and three-dimensional (3D) reconstruction.
A, CT cross-section view showing the systemic and pulmonary outlets from the right ventricle (RV). B, CT cross-section showing the ideal pathway (blue dots) from
the left ventricle (LV) to the aorta (AO). C, 3D reconstruction from CT images showing full heart, with significant subpulmonary obstruction (white arrow) and
pulmonary artery (PA) band. D, 3D reconstruction from CT images showing intracardiac anatomy, viewed from the RV.
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Circ Cardiovasc Imaging. 2019;12:e009297. DOI: 10.1161/CIRCIMAGING.119.009297 July 2019 3
Milano et al; Virtual Reality in Congenital Heart Disease
(left cardiac chambers), usually not accessed during
DORV repair. This increases the spatial understand-
ing of the anatomy before the surgery. In addition,
the possibility to display the VR on a separate monitor
while being used by the leading surgeon (Movie in the
Data Supplement) helped other members of the team
to understand the procedure before and after theater.
Finally, compared with 3D printing, increasingly used in
the management of congenital heart disease, VR has
the advantage to allow unlimited ways of navigation
and manipulation of the patient-specific model by the
surgeon himself at no costs. Such tools can become a
very valuable educational tool which can support inter-
disciplinary communications.
In conclusion, this case-report shows the feasibility
of planning a complex DORV repair by means of 3D
models within a VR environment. VR is a promising tool
to enhance the surgical planning for complex cases.
ARTICLE INFORMATION
The Data Supplement is available at https://www.ahajournals.org/doi/suppl/
10.1161/CIRCIMAGING.119.009297.
Correspondence
Claudio Capelli, PhD, Great Ormond St Hospital for Children, Great Ormond St,
London, WC1N 3JH. Email c.capelli@ucl.ac.uk
Affiliations
UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for
Children, London, UK (E.G.M., E.P., E.S., A.C., S.S., A.M.T., J.M., C.C.). Cardio-
respiratory Unit, Great Ormond Street Hospital for Children NHS Foundation
Trust, London UK (E.G.M., K.H.M., A.M.T., J.M.). Department of Cardiothoracic
Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, Lon-
don, UK (M.K.). Slovak Medical University, Bratislava, Slovakia (M.K.).
Sources of Funding
The authors acknowledge the generous support of La Fondation Dassault Sys-
tèmes and British Heart Foundation (PG/17/6/32797 and PG/16/99/32572).
Disclosures
None.
REFERENCES
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Clin Anat. 2019;32:238–243. doi: 10.1002/ca.23292
Figure 3. The patient-specific three-dimen-
sional (3D) model is used as input for the
virtual reality environment.
A, Presurgical anatomy with possible baffle
pathway to connect ventricular septal defect to
aorta. B, Post surgical results with unobstructed
left ventricle to aorta baffle. C, 3D reconstruc-
tion of the postoperative left sided structures.
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