Virtual Reality Analysis of Three-Dimensional Echocardiographic and Cardiac Computed Tomographic Data Sets

Merging virtual and physical experiences: extended realities in cardiovascular medicine

Technological advancement and the COVID-19 pandemic have brought virtual learning and working into our daily lives. Extended realities (XR), an umbrella term for all the immersive technologies that merge virtual and physical experiences, will undoubtedly be an indispensable part of future clinical practice. The intuitive and three-dimensional nature of XR has great potential to benefit healthcare providers and empower patients and physicians. In the past decade, the implementation of XR into cardiovascular medicine has flourished such that it is now integrated into medical training, patient education, pre-procedural planning, intra-procedural visualization, and post-procedural care. This review article discussed how XR could provide innovative care and complement traditional practice, as well as addressing its limitations and considering its future perspectives.

Left Atrial Thrombus-Are All Atria and Appendages Equal?

Although the left atrial appendage (LAA) seems useless, it has several critical functions that are not fully known yet, such as the causes for being the main origin of cardioembolic stroke. Difficulties arise due to the extreme range of LAA morphologic variability, making the definition of normality challenging and hampering the stratification of thrombotic risk. Furthermore, obtaining quantitative metrics of its anatomy and function from patient data is not straightforward. A multimodality imaging approach, using advanced computational tools for their analysis, allows a complete characterization of the LAA to individualize medical decisions related to left atrial thrombosis patients.

Extended reality for procedural planning and guidance in structural heart disease - a review of the state-of-the-art

Extended reality (XR), which encompasses virtual, augmented and mixed reality, is an emerging medical imaging display platform which enables intuitive and immersive interaction in a three-dimensional space. This technology holds the potential to enhance understanding of complex spatial relationships when planning and guiding cardiac procedures in congenital and structural heart disease moving beyond conventional 2D and 3D image displays. A systematic review of the literature demonstrates a rapid increase in publications describing adoption of this technology. At least 33 XR systems have been described, with many demonstrating proof of concept, but with no specific mention of regulatory approval including some prospective studies. Validation remains limited, and true clinical benefit difficult to measure. This review describes and critically appraises the range of XR technologies and its applications for procedural planning and guidance in structural heart disease while discussing the challenges that need to be overcome in future studies to achieve safe and effective clinical adoption.

3D echocardiography in mitral valve prolapse

Mitral valve prolapse (MVP) is the leading cause of mitral valve surgery. Echocardiography is the principal imaging modality used to diagnose MVP, assess the mitral valve morphology and mitral annulus dynamics, and quantify mitral regurgitation. Three-dimensional (3D) echocardiographic (3DE) imaging represents a consistent innovation in cardiovascular ultrasound in the last decades, and it has been implemented in routine clinical practice for the evaluation of mitral valve diseases. The focus of this review is the role and the advantages of 3DE in the comprehensive evaluation of MVP, intraoperative and intraprocedural monitoring.

Evaluation of a Linear Measurement Tool in Virtual Reality for Assessment of Multimodality Imaging Data-A Phantom Study

This study aimed to evaluate the accuracy and reliability of a virtual reality (VR) system line measurement tool using phantom data across three cardiac imaging modalities: three-dimensional echocardiography (3DE), computed tomography (CT) and magnetic resonance imaging (MRI). The same phantoms were also measured using industry-standard image visualisation software packages. Two participants performed blinded measurements on volume-rendered images of standard phantoms both in VR and on an industry-standard image visualisation platform. The intra- and interrater reliability of the VR measurement method was evaluated by intraclass correlation coefficient (ICC) and coefficient of variance (CV). Measurement accuracy was analysed using Bland−Altman and mean absolute percentage error (MAPE). VR measurements showed good intra- and interobserver reliability (ICC ≥ 0.99, p < 0.05; CV < 10%) across all imaging modalities. MAPE for VR measurements compared to ground truth were 1.6%, 1.6% and 7.7% in MRI, CT and 3DE datasets, respectively. Bland−Altman analysis demonstrated no systematic measurement bias in CT or MRI data in VR compared to ground truth. A small bias toward smaller measurements in 3DE data was seen in both VR (mean −0.52 mm [−0.16 to −0.88]) and the standard platform (mean −0.22 mm [−0.03 to −0.40]) when compared to ground truth. Limits of agreement for measurements across all modalities were similar in VR and standard software. This study has shown good measurement accuracy and reliability of VR in CT and MRI data with a higher MAPE for 3DE data. This may relate to the overall smaller measurement dimensions within the 3DE phantom. Further evaluation is required of all modalities for assessment of measurements <10 mm.

Application of AI in cardiovascular multimodality imaging

Technical advances in artificial intelligence (AI) in cardiac imaging are rapidly improving the reproducibility of this approach and the possibility to reduce time necessary to generate a report. In cardiac computed tomography angiography (CCTA) the main application of AI in clinical practice is focused on detection of stenosis, characterization of coronary plaques, and detection of myocardial ischemia. In cardiac magnetic resonance (CMR) the application of AI is focused on post-processing and particularly on the segmentation of cardiac chambers during late gadolinium enhancement. In echocardiography, the application of AI is focused on segmentation of cardiac chambers and is helpful for valvular function and wall motion abnormalities. The common thread represented by all of these techniques aims to shorten the time of interpretation without loss of information compared to the standard approach. In this review we provide an overview of AI applications in multimodality cardiac imaging.

Left Atrial Thrombus-Are All Atria and Appendages Equal?

Although the left atrial appendage (LAA) seems useless, it has several critical functions that are not fully known yet, such as the causes for being the main origin of cardioembolic stroke. Difficulties arise due to the extreme range of LAA morphologic variability, making the definition of normality challenging and hampering the stratification of thrombotic risk. Furthermore, obtaining quantitative metrics of its anatomy and function from patient data is not straightforward. A multimodality imaging approach, using advanced computational tools for their analysis, allows a complete characterization of the LAA to individualize medical decisions related to left atrial thrombosis patients.

Multimodality cardiac imaging and new display options to broaden our understanding of the tricuspid valve

PURPOSE OF REVIEW

The prognostic impact of tricuspid regurgitation (TR) and the subsequent development of percutaneous procedures targeting the tricuspid valve (TV), has brought to the forefront the role of imaging for the assessment of the forgotten valve. As illustrated in several studies and summarized in this review, currently a multimodality imaging approach is required to understand the pathophysiology of TR, due to the complex TV anatomy and the close relationship between the severity of TR and the extent of the remodeling of the right heart chambers.

RECENT FINDINGS

Recently, the advance in the tranhscatheter treatment of the TV has led to a growing interest in the development of dedicated software packages and new display modalities to increase our understanding of the TV. As a consequence, a transversal knowledge of the different imaging modalities is required for contemporary cardiac-imaging physicians.

SUMMARY

This review highlights the main features, and the pros and cons of echocardiography, cardiac computed tomography, cardiac magnetic resonance and emerging technologies, as 3D printing and virtual reality, in the assessment of patients with TR.