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Bui et al. Vessel Plus 2021;6:31 https://dx.doi.org/10.20517/2574-1209.2021.97 Page 7 of 12

[37]
the quality of the surgery .

Although the option of combining VR with haptic feedback devices is available, some argue that it is still
lacking compared to real tactile stimulation like cadavers or 3D printed models. Hence, VR simulation with
haptic feedback devices might be more appropriate for the surgical practice of procedures that require
limited haptic feedback, such as those involving catheter or wire-based instruments .
[1]
Lastly, the use of VR is limited to individual use due to the lack of face-to-face communication, but its
utility in team-based situations can be further explored . Kim et al. described a study that compared the
[37]
[34]
use of conventional 2D images, non-immersive VR, and fully-immersive VR in the diagnostic accuracy and
group discussions of congenital heart diseases among residents and medical students. The study concluded
that group discussions using full immersive VR were preferred, and it also led to a higher diagnostic
[34]
accuracy over the other two imaging modalities . This demonstrates that despite the current limitations of
VR, its use in the surgical field can be further explored.

Augmented reality in surgery
AR enhances the real world through interactive elements. Like other 3D imaging modalities, it has become
increasingly helpful in assisting surgeons with the identification of anatomical structures to minimize
surgical complications and reduce operating hours. Images on augmented reality are created in a similar
way to virtual reality, and they mostly differ in the equipment required.

AR has allowed surgeons performing laparoscopic procedures to have a better comprehension of the
structures lying beneath the visible organs and the ability to visualize relationships between anatomical
structures, overall improving the safety of the procedure and surgical outcomes . In cardiology, AR has
[11]
been utilized in various minimally invasive applications, and is commonly used in combination with
transesophageal echocardiography (TEE). For example, Currie et al. discussed the usage of an AR and
[14]
TEE guidance system for transcatheter aortic valve implantation deployment in patients with severe aortic
stenosis. It is imperative to be accurate in the positioning during the deployment of the stent to prevent
complications like embolism or atrioventricular heart block. Furthermore, current procedures usually rely
on the use of fluoroscopy with contrast mediums which can increase the risk of acute kidney injury, making
the procedure a contraindication in certain patient populations. The integration of AR and TEE as a
guidance system addresses these issues by eliminating the use of contrast mediums. It was also reported that
procedural errors were lower with the use of the AR guidance system, indicating an overall good valve stent
[14]
positioning .
The improved procedural accuracy from integrating AR and TEE with minimally invasive procedures was
also shown in a study involving mitral valve (MV) repair. Ender et al. compared the use of AR and TEE to
[45]
determine MV annuloplasty size with the current gold standard conventional surgical sizing in 50 patients.
Obtaining the right size is essential to avoid complications like mitral regurgitation or mitral stenosis. The
team concluded that the AR and TEE system did accurately predict the annuloplasty ring size and
anticipated other utility with the system in assisting surgeons with limited experience with MV repair .
[45]
[15]
Also, Chu et al. reported that the addition of AR guidance into MV repair procedures demonstrated a
threefold increase in accuracy of the tool navigation and a fivefold decrease in navigation times, leading to
overall shorter procedural times with fewer complications. The use of AR in other transcatheter procedures
[16]
was explored by Liu et al. , who further reiterates its positive aspects in assisting with pre-procedural
planning, familiarizing with complicated procedures, and as an educational tool for residents and fellows.