# Two cases of direct aortic transcatheter aortic valve implantation via anterior right Mini-thoracotomy after preoperative virtual reality-based simulation: a case report

## TL;DR

This case report shows how virtual reality simulations helped safely perform aortic valve implantation through a small chest incision in two elderly patients.

## Contribution

The paper introduces the use of virtual reality-based simulation for planning direct aortic transcatheter valve implantation via mini-thoracotomy.

## Key findings

- Virtual reality simulation identified optimal puncture sites for two patients, ensuring safe and precise implantation.
- The technique was successfully applied in two elderly patients with aortic stenosis without complications.
- The method shows potential for broader use in cardiac surgery for improved procedural accuracy.

## Abstract

In direct aortic transcatheter aortic valve implantation for patients with aortic stenosis, anterior right mini-thoracotomy presents challenges due to the limited visual field and raises concerns about significant bleeding. Furthermore, identifying the site closest to the ascending aorta while maintaining an adequate distance from the annulus is challenging. We report on the effectiveness of our preoperative simulation using virtual reality technology to ensure a safe and precise direct aortic transcatheter aortic valve implantation via anterior right mini-thoracotomy in two patients.

The patients were an 81-year-old man (Patient 1) and an 86-year-old woman (Patient 2) with aortic stenosis; their ascending aorta was closest to the third intercostal space. In Patient 1, virtual reality simulation revealed that, according to the distance and angulation from the annulus, the ideal puncture site was the second intercostal space. Accordingly, an anterior right mini-thoracotomy was performed at the second intercostal space, and a 23-mm SAPIEN 3 valve (Edwards Lifesciences Ltd.) was adequately implanted. Conversely, in Patient 2, the virtual reality assessment indicated that the third intercostal space was the appropriate site of entry. Therefore, anterior right mini-thoracotomy was performed at the third intercostal space, and a 23-mm SAPIEN 3 valve was successfully implanted, without difficulties.

The use of preoperative virtual reality simulation enabled the safe and precise execution of direct aortic transcatheter aortic valve implantation via anterior right mini-thoracotomy. Virtual reality technology is expected to have broader applications in cardiac surgery in the future.