A 52-year-old male was referred with dizziness and found to have a haemodynamically significant atrial septal defect (ASD). Trans-esophageal echocardiography (TEE) (Panel A) revealed a complex ASD with multiple fenestrations (white arrows) and two separate tissue arcades (green stars) on the left atrial side. Due to the complex morphology, a 4D multi-slice computed tomography (MSCT) was performed (Panel B; see Supplementary material online, Video S1), which confirmed the presence and position of the arcades covering the ASD (red arrow). Given the rarity and complexity of the intervention required, international expertise was sought for detailed pre-procedural review of the multi-modality imaging. A virtual heart team (VHT) was set up using virtual reality (VR) technology. Expert imaging and interventional operators over a hundred kilometres away joined the virtual room (Panel C; see Supplementary material online, Video S1) constructed by Medical Imaging XR application (Medicalholodeck, Switzerland) using Oculus glasses (Reality Labs, USA) (black arrow). Physicians were able to visualize and interact (slice, measure, pan, rotate, zoom) with the TEE and 4D MSCT data (yellow star) in a real 3D space in a more intuitive manner, with built-in real-time audiovisual communication. The VHT was able to discern that the previously suspected multiple defect was in fact one large defect sequestered by the arcades (see Supplementary material online, Video S1) which is a very rare case for percutaneous closure. This finding was not perceived during the standard MSCT data analysis on flat screens. Percutaneous ASD closure was proposed in unique manner with advanced imaging support after prior electrosection of the arcades. The procedure was successfully performed according to the VHT strategy using the 28 mm AMPLATZER septal occluder (Abbott, USA) (Panel D). This approach demonstrates the utility of integrating VR technology to support pre-procedural planning for complex structural heart interventions, by facilitating experts to connect together and intuitively interact in real 3D space with multi-modality imaging data.
Supplementary Material
Contributor Information
Adriana Złahoda-Huzior, Department of Measurement and Electronics, AGH University of Science and Technology, Al. Mickiewicza 30, 30-059 Krakow, Poland; Digital Innovations & Robotics Hub, Clinical Research Center Intercard, Al.Plk.Wl.Beliny-Prazmowskiego 60, 31-514 Krakow, Poland.
Jaroslav Januska, Cardiocentrum Trinec, Agel Trinec Podlesi Hospital, Konska 453, 73-961 Trinec, Czech Republic.
Jan Hecko, Department of Cybernetics and Biomedical Engineering, VSB - Technical University of Ostrava, 17 Listopadu, Poruba, 70800 Ostrava, Czech Republic.
Arif Khokhar, Digital Innovations & Robotics Hub, Clinical Research Center Intercard, Al.Plk.Wl.Beliny-Prazmowskiego 60, 31-514 Krakow, Poland; Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS London, UK.
Dariusz Dudek, Center for Digital Medicine and Robotics, Jagiellonian University Medical College, ul. Kopernika 7E, 33-332 Kraków, Poland; Maria Cecilia Hospital, Via Corriera 1, 48033 Cotignola RA, Italy.
Supplementary material
Supplementary material is available at European Heart Journal – Case Reports.
Acknowledgements: Authors would like to acknowledge Łukasz Rekść, MD, Maria Kundzierewicz, Paweł Zakrzewski, Artur Leśniak, Hubert Borecki (Digital Innovations & Robotics Hub, Poland), Tomasz Kupidura (Medicalholodeck, Switzerland), and Maciej Stanuch (MedApp S.A., Poland) for their contribution.
Consent: The authors confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
Funding: None declared.
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