Reimagining the heart: the expanding landscape of advanced cardiovascular visualisation

In this issue of Open Heart, two complementary contributions examine how emerging visualisation technologies are reshaping cardiovascular imaging and management of congenital heart diseases (CHD). Avakian and Umair present a thoughtful viewpoint on cinematic rendering (CR)¹, while Arero et al, in their systematic review and meta-analysis, evaluate the clinical impact of three-dimensional (3D) printing in CHD.² Though distinct in execution, one computational and the other physical, both reflect a broader transformation in cardiovascular imaging. Together, these contributions underscore a fundamental shift. Cardiovascular imaging is transitioning from a tool of depiction to a platform for cognition, simulation and decision-making.

For decades, progress in cardiovascular imaging centred on acquisition, higher resolution, faster temporal sampling and lower radiation exposure. Interpretation, however, remained largely planar. Even with multiplanar reconstructions and conventional 3D volume rendering, clinicians mentally reconstruct complex spatial relationships. Advances in visualisation are now addressing this gap.

Conventional volume rendering relies on simplified virtual light sources in which voxel intensities are mapped to opacity and colour functions. While effective and widely adopted, these approaches have limited light–tissue interaction. In contrast, CR simulates multiple light paths interacting with tissue densities, approximating real-world photometric behaviour. The distinction is not merely aesthetic. Monte Carlo-based path tracing algorithms simulate global illumination, with indirect lighting, soft shadows and attenuation effects, principles adapted from advanced computer graphics.¹³,⁵ Improved depth perception and contour realisation potentially reduce visual ambiguity in complex intracardiac relationships, outflow tract anatomy or valvular morphology. Importantly, as acknowledged by Avakian and Umair, CR does not create new diagnostic information; it reorganises existing data into a visual format that may lower cognitive load and facilitate multidisciplinary discussion. In that sense, it functions less as a diagnostic breakthrough and more as a cognitive bridge.¹ Nonetheless, unlike surface-rendering techniques as in 3D printing, CR preserves volumetric continuity, offering a more complete anatomical representation.

3D printing brings visualisation into the physical domain. Its greatest value likely lies not in routine lesions but in anatomies where conventional imaging fails to provide intuitive spatial clarity. The accompanying meta-analysis suggests that patient-specific 3D heart models are associated with modification of surgical planning and possible reductions in operative time in complex CHD.² This effort to pool outcomes represents a meaningful step beyond earlier descriptive reports, which largely emphasised feasibility, educational value and perceived surgical confidence.⁶,⁸ The present meta-analysis advances the field by attempting quantitative synthesis. At the same time, it highlights limitations in the existing literature, including observational study designs, modest sample sizes, lesion heterogeneity and variability in outcome definitions.

Technological refinement in 3D printing has also progressed substantially. Contemporary cardiac models increasingly employ flexible photopolymers and silicone-based elastomers designed to approximate tissue compliance.⁹ Multi-material printing permits region-specific stiffness within a single construct, enabling simulation of suturing, patch placement and device deployment. These developments move 3D printing beyond representation toward functional rehearsal and may influence procedural strategy and efficiency in complex CHD. Emerging workflows that integrate echocardiographic and CT datasets further enhance anatomical fidelity of the models.

The broader trajectory of cardiovascular imaging is difficult to ignore. Advances in segmentation software, computational rendering power, additive manufacturing and material science are converging. Technologies that were experimental a decade ago are now undergoing structured evaluation. Virtual dissection is increasingly integrated into planning workflows rather than confined to demonstration settings.¹⁰,¹² Emerging tools such as augmented and virtual reality further extend this spectrum of advanced visualisation, enabling interactive engagement with volumetric datasets and enhancing spatial understanding.^{13 14} Together, these approaches share a common goal of reducing interpretive friction in complex anatomy.

Both CR and 3D printing should also be viewed in the context of parallel advances in image acquisition. The maturation of CT and MRI, offering better spatial resolution, temporal fidelity, motion correction and tissue characterisation, has provided the raw anatomical detail that allows these advanced visualisation techniques to realise their full potential. In that sense, these technologies represent not isolated innovations but the natural progression of an ever-evolving continuum of cardiovascular imaging and visualisation. The growth of the literature itself reflects this evolution. Publications on 3D printing in CHD were sparse before 2013, followed by a steady and then marked acceleration over the past decade. A similar trajectory is observed for CR in cardiovascular applications, particularly after 2018.

Yet sophistication alone cannot justify routine adoption. As articulated by Shneiderman, the purpose of visualisation is insight, not images, a principle that reframes how these technologies should be evaluated.¹⁵ The key question is not whether these tools are visually compelling, but whether they truly enhance understanding, improve decision-making and translate into better outcomes. The current meta-analysis offers an encouraging trend but also highlights key limitations. Surgical plan modification, while interesting, does not inherently imply improved care. Reductions in operative duration are promising but derive from heterogeneous cohorts. Lesion-specific conclusions remain constrained by limited numbers, and prospective randomised evidence is scarce. These limitations are not shortcomings unique to the authors’ effort; they reflect the structural realities of a developing field.

Cardiovascular imaging now stands at an inflection point. Structural and congenital interventions are increasingly image-dependent, procedural complexity continues to rise and heart-team decision-making requires shared spatial understanding. The broadening visualisation portfolio reflects not only technological diversification but also permits reimagining of how anatomical knowledge is constructed and communicated.

The excitement surrounding this evolution is justified. Imaging and visualisation capabilities are expanding, driven by both technological innovation and clinical demand. Enthusiasm, however, must remain anchored in rigour. Standardised outcomes, lesion-specific analyses, prospective studies and cost-effectiveness evaluations are essential to define optimal clinical integration. Reimagining the heart, therefore, is not simply an exercise in aesthetics. The challenge ahead is not to adopt these technologies, but to define where they meaningfully change decisions, outcomes and ultimately, patient care.