Mixed reality navigation of a systemic venous baffle obstruction: Unravelling the percutaneous approach in atrial switch operation

Congenital heart diseases in adulthood (ACHD) are an increasing evidence, hence the need of interventional procedures due to late-onset complications of early-life corrective surgery. Systemic venous baffle (SVB) obstruction occurs in up to 10% of transposition of great arteries after atrial switch operation (TGA-ASO, Supplementary material online, Movie S1) and stenting is the first-line recommended treatment. However, SVB arrangement with the pulmonary systemic baffle remains challenging to interpret, representing a possible limitation for transcatheter approach. Herein, we exploited a novel image-based platform to set up the percutaneous relief of a superior vena cava (SVC) pathway obstruction in TGA-ASO. Three-dimensional (3D) pre-catheterization anatomy (Panel A) was investigated employing a holographic augmented reality prototype (Panel A1, ARTINESS, Milan, Italy) to directly inspect the 3D anatomy (Panel A2) and perceive the severity of SVB stenosis and its longitudinal extension (Panel A3; Supplementary material online, Movie S2). Multi-planar analysis of SVC cross-sections (Panel B1) effectively supported the stent sizing. A 48-mm ANDRA stent (Andramed, Reutlingen, Germany) was deployed on the stenotic baffle and post-dilated with a balloon-in-balloon catheter 18 50 mm (BiBVR Catheter, NUMED, Hopkinton, NY, USA; Supplementary material online, Movie S3); peak-to-peak SVC gradient reverted from 6 mmHg to a baseline value. Post-catheterization 3D computer tomography scan reconstruction was navigated through mixed reality, pinpointing the results of the procedure (Panel B2, Supplementary material online, Movie S4). By enhancing the structural ACHD comprehension, 3D analysis and holographic navigation are promising tools for diagnostic and therapeutic applications, with a glance on their educational potentials