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International Journal of Bioprinting Evaluation of advanced visual computing solutions for the left atrial appendage occlusion

3D printing is a tool routinely used in certain a valuable technology in cardiology to support clinical
cardiology fields, especially when dealing with abnormal decisions, such as interventional planning, diagnosis, and
heart anatomies , such as in congenital heart disease device optimization [28,29] . For instance, the commercial
[13]
[14]
and pediatric applications , providing the clinician a software HEARTguideTM (FEops NV, Gent, Belgium)
better understanding of 3D cardiac anatomy. The clinical provides patient-specific structural simulations of LAAO
translation of 3D printing has been made possible due deployments with different device configurations ,
[30]
to the reduction of printer costs with simple rigid plastic but without user interaction and lacking functional
materials, although more sophisticated printers and flexible information. Computational fluid dynamics (CFD)
materials mimicking tissue properties are available at a solvers compute flow and pressure throughout a well-
higher cost. Adaptation of 3D printing in clinical care and defined geometrical domain and can provide useful
procedural planning has already demonstrated a reduction functional information about blood flow patterns with
in early operator learning curve or in centers without high spatial resolution, currently unattainable with in vivo
previous experience on transcatheter interventions [2,15-17] . imaging techniques. Different therapeutic scenarios can
Several studies have evaluated the added value of be in silico tested with CFD before the intervention, thus
[31]
3D-printed models for training and planning of LAAO reducing operation costs with enhanced efficiency and
interventions . However, Conti et al. recently compared accelerating research and development understanding of
[18]
[2]
3D printing recommendations and implanted devices, with fluid mechanics within device testing . Regarding LAA
an agreement of only 35% . Moreover, computational applications, several researchers have run CFD simulations
[19]
costs and time required for models to be printed with to study blood flow in the left atria [32-35] , including after the
realistic materials are not negligible in the clinical workflow. implantation of LAAO to find the optimal configuration
of device [12,36,37] . However, comprehensive pre-operative
Although in an earlier phase of development and simulations may take between hours and days depending
application in the biomedical field, there already exist on the complexity of the anatomy and potential interactions
proof-of-concept studies of using VR technologies for between cardiac tissue and the blood flow to be modeled ,
[2]
cardiac devices such as the pre-operative planning of thus limiting its application in a clinical environment.
transcatheter closure of cardiac deficiencies, such as
ventricular septal or sinus venous defects [21,22] . Nam et In this paper, we present the evaluation of several
[20]
al. used new functionalities of the 3D-Slicer open-source advanced visual computing solutions for the planning of
[23]
software (i.e., link with VR headsets) to develop a tool for LAAO interventions (i.e., web-based platform with 3D
the virtual testing, selection, and placement of transcatheter imaging visualization, VR, and in silico fluid simulations),
together with 3D printing with standard and affordable
device closures of atrial and ventricular septal defects. materials. 3D imaging data from CT scans of five patients,
Narang et al. recently demonstrated a reduction in who were the candidates for LAAO implantation, were
[24]
measurement variability and time required when exploring visualized with different visual computing and 3D
3D echocardiography and CT images in different cardiac printing technologies by six domain knowledge experts
pathologies, with users reporting easy manipulation of VR (three interventional and three imaging cardiologists).
models, diagnostic quality visualization of the anatomy, During the practical session, they were asked to decide the
and high confidence in the measurements. As for LAAO LAAO device settings after using each technology for each
devices, the EchoPixel True 3D VR Solution (EchoPixel, patient-specific case, and to fill in a usability questionnaire
Inc., Mountain View, California, United States) allows to and some open questions to assess the adding value,
visualize CT scans and perform a “device-in-anatomy” limitations, and requirements for clinical translation of
simulation for LAAO pre-procedural planning . Zbronski each one of the evaluated technologies.
[25]
et al. also visualized CT-derived LA anatomies before
[26]
and during the occlusion procedure with the AR HoloLens 2. Materials and methods
headset, which is an enhancement according to clinicians. Figure 1 shows a general overview of the evaluation
Finally, Medina et al. developed a VR-based platform
[27]
(VRIDAA) for the visualization/analysis of LAA anatomies pipeline followed in our study. The original 3D CT scans
and the most appropriate occlusion devices to be implanted; of five patients, acquired before the LAAO intervention,
were segmented to derive a binary mask of the left atria,
the platform is regarded by clinical users as a source of including the left atrial appendage. Subsequently, a 3D
motivation for trainees who can better understand the model in the form of a surface mesh was generated and
required approach before the intervention.
introduced, together with the gray-level 3D scan if
In silico simulations from virtual physiological models required, to the specific processing workflow of each one of
of the heart, also known as digital twins, are emerging as the evaluated computing technologies (e.g., web-based 3D

Volume 9 Issue 1 (2023) 260 https://doi.org/10.18063/ijb.v9i1.640