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Page 2 of 12 Bui et al. Vessel Plus 2021;6:31 https://dx.doi.org/10.20517/2574-1209.2021.97

In medicine, 3D printing allows the production of surgical instruments, implants, and pathological organs
using imaging files from computed tomography (CT) or magnetic resonance imaging (MRI). These solid
and graspable objects give surgeons a better understanding of the anatomy and help improve patient-
physician communication. Hence, it has the potential to reduce the duration of surgery while minimizing
the risk of infection and complication .
[3,4]
The development of advanced visualization technology, which includes virtual reality (VR) and augmented
reality (AR), has also revolutionized surgical training as it allows repeated use with varying difficulties and
[1,5]
the ability to self-evaluate after every use . VR refers to a computer-simulated experience in a synthetic
world. In surgery, VR has been experimented for surgical planning, as well as in education and preoperative
[6,7]
training . It can also be used as a distraction tool for patients during procedures to minimize the need for
anesthesia, resulting in faster recovery time and decreased anesthetic complications . Postoperatively, it can
[8]
be used to decrease pain and reduce psychological stress experienced primarily in cardiac surgery . Like
[9]
[10]
VR, AR involves virtual images but those superimposed in the real world instead . Its use has increased in
laparoscopic and minimally invasive procedures as it allows for precise identification of important internal
structures that are often difficult to see on a 2D image. This translates to easier surgical planning, improved
surgical outcomes, and better patient education [11-16] .

This review provides an overview of the current applications of 3D printing, VR, and AR in surgery, and
looks further into its role in congenital heart surgery.

3D printing in surgery
The use of 3D printing has gained widespread popularity in the field of congenital heart defect surgery due
[17]
to its ability to display spatial relationships and complex cardiac anatomy . 3D cardiac models have been
used for presurgical planning of a variety of congenital heart defect, ranging from simple atrial septal defect
or ventricular septal defect (VSD) lesions to complex cardiac lesions, with the most common application
being for double outlet right ventricle (DORV) repair planning .
[18]
To create a 3D cardiac model, imaging using cardiac CT, MRI, or 3D echocardiogram is performed, given
their ability to distinguish blood from the myocardium and vessel wall. Segmentation of the images is then
performed, and the result is later converted from a Digital Imaging and Communication in Medicine
(DICOM) file to a file format compatible with printing. The printable file is then uploaded to the software
program of a 3D printer, and materials are selected based on the utility of the heart model .
[19]

In cardiology, surgeons use patient-specific 3D printed cardiac models as surgical guides to determine the
pathology, areas to resect, and to gain hands-on practice before surgery . Patients with congenital heart
[19]
diseases often have a variety of complex cardiac anatomy that is difficult to visualize using 2D. This is
especially crucial in cardiac defect repair surgery for children where thorax and heart sizes are small, making
it difficult to visualize the actual surgical field .
[19]
Garekar et al. discussed the unique cardiac anatomy of five patients with DORV and remote VSD. The
[20]
creation of 3D cardiac models for these patients allowed surgeons to understand the relationship between
the great arteries, ventricular mass, and VSD, decide on the surgical approach, and assist with presurgical
planning. For patients who underwent surgery, intraoperative anatomy was in agreement with the model,
and it helped boost the team’s confidence intraoperatively .
[20]