A patient-based realistic simulation platform to train future electrophysiologists to complex ablation procedures
Authors: Pruvot E , Schwitter J , Antiochos P , Masi A , Teres Castillo C , Bacha N , Ballan H , Wickramasinghe U , Erard R , Corazza G , Le Bloa M , Pascale P , Ascione C , Domenichini G , Caron G 
Published: May 2024

Abstract

Title
An immersive catheter ablation platform based on patients’ 3D heart model for the simulation and training of future electrophysiologists.

Background
Arrhythmias are on the rise worldwide due to the ageing of the population. Projections urge to train the next generation of electrophysiologists (EPs) to perform catheter (CATH) ablation (CA) of arrhythmias. Training of future EPs relies mostly on a companionship, where teaching of CATH steerability is made on patients (pts) referred for procedures. While several other domains have established the utility of simulators to speed up learning process, increase safety and establish procedure road maps, dedicated simulators for EPs based on pts’ real anatomy do not exist yet.

Purpose
To speed up the handling of steerable CATH on MRI-based 3D heart models to optimize ablation road maps in pts referred for complex arrhythmias.

Methods
ARTS is an Artificial Intelligence and Augmented Reality-based platform comprising two key components: HeARTS and ARTSim. HeARTS is designed to automatically generate 3D heart models from pts’ MRI scans. ARTSim is a CA simulator that utilizes the 3D heart models of the pts for the planning and simulation of CA procedures. This simulator incorporates innovative techniques for digitizing and tracking the movements of a physical catheter in real time, and enabling its navigation within a completely virtual heart. With this technology, the CATH can be precisely steered to various heart locations, including the right and left (LA) atrium, the coronary sinus, and the right and left (LV) ventricles.

Results
Panel A of the figure shows the mannequin used for the simulator, where a real ablation CATH is introduced within the pt’s heart through a venous introducer. Panel B shows right anterior oblique (RAO) and modified RAO views of a pt suffering from a typical right atrial flutter. Note the presence of yellow tags positioned along the cavotricuspid isthmus (CTI) that the trainee must reach for a programmable duration using the shaft and the handle of the CATH shown in panel A. Panel C shows the virtual ablation CATH in green positioned on the target dots of the CTI. The pink color indicates that the trainee reached the desired target, which became red when the CATH remained stable at the same location for a duration of 5 sec (i.e. stability) with a force &gt;5g (i.e. efficacy) and &lt;20g (i.e. safety).

Conclusions
Herein, we present ARTS, a realistic CA simulation platform for the training of future EPs, that offers all the typical characteristics of 3D navigation including steerability, stability measurements and the force applied. Importantly, ARTS is based on the true anatomy of the pts, hence might be used to establish and discuss roadmaps to optimize procedures efficacy and safety. Version 2.0, foreseen early 2024, will include 3D late gadolinium enhancement and transseptal puncture for virtual LA and LV procedures, and later on activation times and myocardial voltage.Figure