Augmented Reality Image Guidance during Off-Pump Mitral Valve Replacement through the Guiraudon Universal Cardiac Introducer

Objective We report our experience with ultrasound augmented reality (US-AR) guidance for mitral valve prosthesis (MVP) implantation in the pig using off-pump, closed, beating intracardiac access through the Guiraudon Universal Cardiac Introducer attached to the left atrial appendage. Methods Before testing US-AR guidance, a feasibility pilot study on nine pigs was performed using US alone. US-AR guidance, tested on a heart phantom, was subsequently used in three pigs (~65 kg) using a tracked transesophageal echocardiography probe, augmented with registration of a 3D computed tomography scan, and virtual representation of the MVP and clip-delivering tool (Clipper); three pigs were used to test feature-based registration. Results Navigation of the MVP was facilitated by the 3D anatomic display. AR displayed the MVP and the Clipper within the Atamai Viewer, with excellent accuracy for tool placement. Positioning the Clipper was hampered by the design of the MVP holder and Clipper. These limitations were well displayed by AR, which provided guidance for improved design of tools. Conclusions US-AR provided informative image guidance. It documented the flaws of the current implantation technology. This information could not be obtained by any other method of evaluation. These evaluations provided guidance for designing an integrated tool: combining an unobtrusive valve holder that allows the MVP to function properly as soon as positioned, and an anchoring system, with clips that can be released one at a time, and retracted if necessary, for optimal results. The portability of Real-time US-AR may prove to be the ideal practical image guidance system for all closed intracardiac interventions.