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

The creation of virtual reality images also requires medical imaging that captures all aspects of the heart.
The imaging data is then segmented, analyzed, and converted from a DICOM file to a file type appropriate
for uploading to virtual reality software. Devices such as headsets, controllers, and base stations can be
connected to allow the manipulation of virtual images [2,31] .

The use of VR in congenital cardiac surgery is mainly for surgical planning and preoperative training. It is
especially beneficial in this field given the anatomical variability that can present with each unique patient,
thus affecting the approach of the procedure and the extent of repair needed [38,39] . Pushparajah et al.
[38]
performed a study comparing the understanding of patients with atrioventricular valve lesions and the
chosen surgical approach of surgeons that viewed 2D and 3D echocardiograms vs. surgeons that made use
of VR images. He concluded that surgeons felt more confident about the pathology and potential surgical
approach after viewing images on the VR platform. They also reported that VR was superior to 3D cardiac
models since it provided surgeons insight into internal structures like valves. It also allowed visualization of
[38]
dynamic changes in the heart and depth perception, which can be critical in certain patients .

A case about the separation of thoracopagus conjoined twins was described by Juhnke et al. , where VR
[2]
was used to analyze the complex anatomy of the twins and, upon discussion, led to modifications to a more
efficient surgical approach. With the aid of VR, the surgeons were able to identify relationships between the
two hearts and color code structures that belonged to each twin. This revealed incision depths required to
reach the interatrial communication, which was essential to be closed due to its high operative mortality
[2]
before attempting complete separation of the twins .

Ayerbe et al. described a nine-year-old female with DORV and malposition of the great arteries who
[40]
experienced homograft dysfunction with severe stenosis eight years after undergoing correction by the
Rastelli technique. With the use of VR from CT angiography images, they navigated through the complex
anatomy, inspected internal structures, and were able to identify the approach for surgical intervention .
[40]
[41]
Ong et al. discussed the use of VR in two patients with congenital heart disease and reported accurate
anatomical VR representations compared to intraoperative findings. Knecht et al. reported a case of a 37-
[42]
year-old male with congenital heart disease and how VR was used to reconstruct the complex heart
anatomy from CT scans for pre-procedural planning and guidance of the catheter ablation procedure. VR
has also been proven useful in the analysis of patients with sinus venosus defects given its anatomical
variants and in investigating the possibility of transcatheter closure with covered stents .
[39]
Limitations in virtual reality
Like other innovative 3D visualization modalities, the cost of setting up a VR system is up to thousands of
dollars and can be a limiting factor. The cost is even higher if haptic feedback devices are factored in.
Additionally, there are limitations on both the hardware and software aspects of VR. Some users can find
the size, comfort, or battery life of the device unpleasant, and others may get motion-sick from experience.
Furthermore, designing surgical simulations to meet the different technical demands of each surgical
specialty can be a difficult task [1,5,43,44] .

Given that the main usage of VR is in analyzing complex anatomy, presurgical planning, and educational
surgical practice, some argue that a formal assessment with defined outcomes needs to be in place to
account for the surgeons’ performance before operating on a real patient [5,37] . VR systems should also
explore the possibility of assessing the surgeon’s non-technical skills during the procedure, such as
communication, situation awareness, and task management skills, which can all affect