{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T09:35:43Z","timestamp":1783762543602,"version":"3.55.0"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"3","license":[{"start":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T00:00:00Z","timestamp":1762300800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T00:00:00Z","timestamp":1762300800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Jump ARCHES","award":["P366"],"award-info":[{"award-number":["P366"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Int J CARS"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Virtual reality (VR) has attracted attention in healthcare for many promising applications including pre-surgical planning. Currently, there exists a critical gap in comprehension of the impact of VR on physicians\u2019 thinking. Self-reported data from surveys and metrics based on confidence and task completion may not yield sufficiently detailed understanding of the complex decision making and cognitive load experienced by surgeons during VR-based pre-surgical planning.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Our research aims to address the gap in understanding the impact of VR on physicians\u2019 mental models through a novel methodology of self-directed think-aloud protocols, offering deeper perspectives into physicians\u2019 thought processes within the virtual 3D environment. We performed qualitative analysis of recorded verbalizations and actions in VR in addition to quantitative measures from the NASA task load index (NASA-TLX). Analysis was conducted to identify thematic sequences in VR which influenced clinical decision making when reviewing patient anatomy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We find a significant increase in reported physician confidence in understanding of the patient anatomy from before VR to after (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.012) and identified several common patterns of 3D exploration of the anatomy in VR. Physicians also reported low cognitive stress on the NASA-TLX.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Our findings indicate VR has value beyond simulating surgery, helping physicians to confirm findings from conventional medical imaging, visualize approaches with detail, and help make complex decisions while mentally preparing for surgery. These findings provide evidence that VR and related 3D visualization are helpful for pre-surgical planning of complex cases.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11548-025-03542-7","type":"journal-article","created":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T15:26:43Z","timestamp":1762356403000},"page":"595-605","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Assessing the impact of virtual reality on surgeons\u2019 mental models of complex congenital heart cases"],"prefix":"10.1007","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3998-5199","authenticated-orcid":false,"given":"Eliot","family":"Bethke","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew T.","family":"Bramlet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley P.","family":"Sutton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James L.","family":"Evans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ainsley","family":"Hanner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley","family":"Tran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brendan","family":"O\u2019Rourke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nina","family":"Soofi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer R.","family":"Amos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,11,5]]},"reference":[{"key":"3542_CR1","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1016\/j.cognition.2011.12.004","volume":"123","author":"B Wu","year":"2012","unstructured":"Wu B, Klatzky RL, Stetten GD (2012) Mental visualization of objects from cross-sectional images. Cognition 123:33\u201349. https:\/\/doi.org\/10.1016\/j.cognition.2011.12.004","journal-title":"Cognition"},{"key":"3542_CR2","doi-asserted-by":"publisher","first-page":"888","DOI":"10.1111\/medu.12759","volume":"49","author":"EF Ibrahim","year":"2015","unstructured":"Ibrahim EF, Richardson MD, Nestel D (2015) Mental imagery and learning: a qualitative study in orthopaedic trauma surgery. Med Educ 49:888\u2013900. https:\/\/doi.org\/10.1111\/medu.12759","journal-title":"Med Educ"},{"key":"3542_CR3","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1007\/s10111-012-0227-6","volume":"15","author":"E Varga","year":"2013","unstructured":"Varga E, Pattynama PMT, Freudenthal A (2013) Manipulation of mental models of anatomy in interventional radiology and its consequences for design of human\u2013computer interaction. Cogn Technol Work 15:457\u2013473. https:\/\/doi.org\/10.1007\/s10111-012-0227-6","journal-title":"Cogn Technol Work"},{"key":"3542_CR4","doi-asserted-by":"crossref","unstructured":"Mayr E, Schreder G, Smuc M, Windhager F (2016) Looking at the Representations in our Mind: Measuring Mental Models of Information Visualizations. In: Proceedings of the Sixth Workshop on Beyond Time and Errors on Novel Evaluation Methods for Visualization. Association for Computing Machinery, New York, NY, USA, pp 96\u2013103","DOI":"10.1145\/2993901.2993914"},{"key":"3542_CR5","doi-asserted-by":"publisher","first-page":"269","DOI":"10.1177\/1555343418773236","volume":"12","author":"CS Furlough","year":"2018","unstructured":"Furlough CS, Gillan DJ (2018) Mental models: structural differences and the role of experience. J Cogn Eng Decis Mak 12:269\u2013287. https:\/\/doi.org\/10.1177\/1555343418773236","journal-title":"J Cogn Eng Decis Mak"},{"key":"3542_CR6","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1016\/j.jacbts.2017.11.009","volume":"3","author":"JNA Silva","year":"2018","unstructured":"Silva JNA, Southworth M, Raptis C, Silva J (2018) Emerging applications of virtual reality in cardiovascular medicine. JACC Basic Transl Sci 3:420\u2013430. https:\/\/doi.org\/10.1016\/j.jacbts.2017.11.009","journal-title":"JACC Basic Transl Sci"},{"key":"3542_CR7","doi-asserted-by":"publisher","first-page":"70","DOI":"10.1117\/12.2318677","volume-title":"Biomedical Imaging and Sensing Conference","author":"T Pladere","year":"2018","unstructured":"Pladere T, Konosonoka V, Panke K, Krumina G (2018) Visual search efficiency depending on spatial layout of stimuli in volumetric image. In: Matoba O, Awatsuji Y, Luo Y, Yatagai T, Aizu Y (eds) Biomedical Imaging and Sensing Conference. SPIE, Yokohama, Japan, p 70"},{"key":"3542_CR8","doi-asserted-by":"publisher","DOI":"10.2196\/12008","volume":"6","author":"S Napa","year":"2019","unstructured":"Napa S, Moore M, Bardyn T (2019) Advancing cardiac surgery case planning and case review conferences using virtual reality in medical libraries: evaluation of the usability of two virtual reality apps. JMIR Hum Factors 6:e12008. https:\/\/doi.org\/10.2196\/12008","journal-title":"JMIR Hum Factors"},{"key":"3542_CR9","doi-asserted-by":"publisher","first-page":"687","DOI":"10.1007\/s00345-021-03841-z","volume":"40","author":"A Fujihara","year":"2022","unstructured":"Fujihara A, Ukimura O (2022) Virtual reality of three-dimensional surgical field for surgical planning and intraoperative management. World J Urol 40:687\u2013696. https:\/\/doi.org\/10.1007\/s00345-021-03841-z","journal-title":"World J Urol"},{"key":"3542_CR10","doi-asserted-by":"publisher","DOI":"10.21037\/atm-21-512","volume":"9","author":"F Huettl","year":"2021","unstructured":"Huettl F, Saalfeld P, Hansen C, Preim B, Poplawski A, Kneist W, Lang H, Huber T (2021) Virtual reality and 3D printing improve preoperative visualization of 3D liver reconstructions-results from a preclinical comparison of presentation modalities and user\u2019s preference. Ann Transl Med 9:1074. https:\/\/doi.org\/10.21037\/atm-21-512","journal-title":"Ann Transl Med"},{"key":"3542_CR11","doi-asserted-by":"publisher","DOI":"10.3389\/fsurg.2022.821060","volume":"9","author":"AV Reinschluessel","year":"2022","unstructured":"Reinschluessel AV, Muender T, Salzmann D, D\u00f6ring T, Malaka R, Weyhe D (2022) Virtual reality for surgical planning \u2013 evaluation based on two liver tumor resections. Front Surg 9:821060. https:\/\/doi.org\/10.3389\/fsurg.2022.821060","journal-title":"Front Surg"},{"key":"3542_CR12","doi-asserted-by":"publisher","first-page":"831","DOI":"10.1016\/j.intcom.2004.05.001","volume":"16","author":"A Sutcliffe","year":"2004","unstructured":"Sutcliffe A, Gault B (2004) Heuristic evaluation of virtual reality applications. Interact Comput 16:831\u2013849. https:\/\/doi.org\/10.1016\/j.intcom.2004.05.001","journal-title":"Interact Comput"},{"key":"3542_CR13","doi-asserted-by":"publisher","DOI":"10.1080\/10447318.2022.2161238","author":"X Guo","year":"2023","unstructured":"Guo X, Kumar Nerella K, Dong J, Qian Z, Chen Y (2023) Understanding pitfalls and opportunities of applying heuristic evaluation methods to VR training systems: an empirical study. Int J Human-Comput Interact. https:\/\/doi.org\/10.1080\/10447318.2022.2161238","journal-title":"Int J Human-Comput Interact"},{"key":"3542_CR14","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1177\/15533506221143235","volume":"30","author":"L Lan","year":"2023","unstructured":"Lan L, Mao RQ, Qiu RY, Kay J, de Sa D (2023) Immersive virtual reality for patient-specific preoperative planning: a systematic review. Surg Innov 30:109\u2013122. https:\/\/doi.org\/10.1177\/15533506221143235","journal-title":"Surg Innov"},{"key":"3542_CR15","doi-asserted-by":"crossref","unstructured":"Hart SG, Staveland LE (1988) Development of NASA-TLX (Task Load Index): Results of Empirical and Theoretical Research. In: Advances in Psychology. Elsevier, pp 139\u2013183","DOI":"10.1016\/S0166-4115(08)62386-9"},{"key":"3542_CR16","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1186\/s41205-016-0004-x","volume":"2","author":"S-J Yoo","year":"2015","unstructured":"Yoo S-J, Thabit O, Kim EK, Ide H, Yim D, Dragulescu A, Seed M, Grosse-Wortmann L, van Arsdell G (2015) 3D printing in medicine of congenital heart diseases. 3D Print Med 2:3. https:\/\/doi.org\/10.1186\/s41205-016-0004-x","journal-title":"3D Print Med"},{"key":"3542_CR17","doi-asserted-by":"publisher","DOI":"10.3791\/62805","author":"MS Mattus","year":"2022","unstructured":"Mattus MS, Ralph TB, Keller SMP, Waltz AL, Bramlet MT (2022) Creation of patient-specific silicone cardiac models with applications in pre-surgical plans and hands-on training. J Vis Exp JoVE. https:\/\/doi.org\/10.3791\/62805","journal-title":"J Vis Exp JoVE"},{"key":"3542_CR18","unstructured":"Enduvo. (2023)"},{"key":"3542_CR19","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1007\/BF00988593","volume":"13","author":"JM Corbin","year":"1990","unstructured":"Corbin JM, Strauss A (1990) Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol 13:3\u201321. https:\/\/doi.org\/10.1007\/BF00988593","journal-title":"Qual Sociol"},{"key":"3542_CR20","unstructured":"Tracy SJ (2019) Qualitative research methods: collecting evidence, crafting analysis, communicating impact, Second edition. Wiley-Blackwell, Hoboken, NJ"},{"key":"3542_CR21","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1037\/h0031619","volume":"76","author":"JL Fleiss","year":"1971","unstructured":"Fleiss JL (1971) Measuring nominal scale agreement among many raters. Psychol Bull 76:378\u2013382. https:\/\/doi.org\/10.1037\/h0031619","journal-title":"Psychol Bull"},{"key":"3542_CR22","doi-asserted-by":"publisher","first-page":"276","DOI":"10.11613\/BM.2012.031","volume":"22","author":"ML McHugh","year":"2012","unstructured":"McHugh ML (2012) Interrater reliability: the kappa statistic. Biochem Med 22:276\u2013282","journal-title":"Biochem Med"},{"key":"3542_CR23","doi-asserted-by":"publisher","first-page":"357","DOI":"10.1111\/chd.12587","volume":"13","author":"CS Ong","year":"2018","unstructured":"Ong CS, Krishnan A, Huang CY, Spevak P, Vricella L, Hibino N, Garcia JR, Gaur L (2018) Role of virtual reality in congenital heart disease. Congenit Heart Dis 13:357\u2013361. https:\/\/doi.org\/10.1111\/chd.12587","journal-title":"Congenit Heart Dis"},{"key":"3542_CR24","doi-asserted-by":"publisher","first-page":"1034","DOI":"10.1007\/s10278-021-00480-z","volume":"34","author":"F Pires","year":"2021","unstructured":"Pires F, Costa C, Dias P (2021) On the use of virtual reality for medical imaging visualization. J Digit Imaging 34:1034\u20131048. https:\/\/doi.org\/10.1007\/s10278-021-00480-z","journal-title":"J Digit Imaging"},{"key":"3542_CR25","doi-asserted-by":"publisher","first-page":"546","DOI":"10.1016\/j.jss.2023.07.001","volume":"291","author":"V Lyuksemburg","year":"2023","unstructured":"Lyuksemburg V, Abou-Hanna J, Marshall JS, Bramlet MT, Waltz AL, Pieta Keller SM, Dwyer A, Orcutt ST (2023) Virtual reality for preoperative planning in complex surgical oncology: a single-center experience. J Surg Res 291:546\u2013556. https:\/\/doi.org\/10.1016\/j.jss.2023.07.001","journal-title":"J Surg Res"},{"key":"3542_CR26","doi-asserted-by":"publisher","DOI":"10.1016\/j.sempedsurg.2024.151387","volume":"33","author":"DJ Robertson","year":"2024","unstructured":"Robertson DJ, Abramson ZR, Davidoff AM, Bramlet MT (2024) Virtual reality applications in pediatric surgery. Semin Pediatr Surg 33:151387. https:\/\/doi.org\/10.1016\/j.sempedsurg.2024.151387","journal-title":"Semin Pediatr Surg"},{"key":"3542_CR27","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1016\/j.wneu.2022.08.042","volume":"167","author":"MR Paro","year":"2022","unstructured":"Paro MR, Hersh DS, Bulsara KR (2022) History of virtual reality and augmented reality in neurosurgical training. World Neurosurg 167:37\u201343. https:\/\/doi.org\/10.1016\/j.wneu.2022.08.042","journal-title":"World Neurosurg"},{"key":"3542_CR28","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1109\/mcg.2006.131","volume":"26","author":"B Reitinger","year":"2006","unstructured":"Reitinger B, Bornik A, Beichel R, Schmalstieg D (2006) Liver surgery planning using virtual reality. IEEE Comput Graph Appl 26:36\u201347. https:\/\/doi.org\/10.1109\/mcg.2006.131","journal-title":"IEEE Comput Graph Appl"},{"key":"3542_CR29","doi-asserted-by":"publisher","first-page":"2824","DOI":"10.1016\/j.joms.2010.06.177","volume":"68","author":"SM Roser","year":"2010","unstructured":"Roser SM, Ramachandra S, Blair H, Grist W, Carlson GW, Christensen AM, Weimer KA, Steed MB (2010) The accuracy of virtual surgical planning in free fibula mandibular reconstruction: comparison of planned and final results. J Oral Maxillofac Surg 68:2824\u20132832. https:\/\/doi.org\/10.1016\/j.joms.2010.06.177","journal-title":"J Oral Maxillofac Surg"},{"key":"3542_CR30","doi-asserted-by":"publisher","first-page":"382","DOI":"10.3171\/JNS\/2008\/108\/2\/0382","volume":"108","author":"AT Stadie","year":"2008","unstructured":"Stadie AT, Kockro RA, Reisch R, Tropine A, Boor S, Stoeter P, Perneczky A (2008) Virtual reality system for planning minimally invasive neurosurgery. Technical note. J Neurosurg 108:382\u2013394. https:\/\/doi.org\/10.3171\/JNS\/2008\/108\/2\/0382","journal-title":"J Neurosurg"},{"key":"3542_CR31","doi-asserted-by":"publisher","first-page":"302","DOI":"10.1016\/j.jse.2014.05.029","volume":"24","author":"G Walch","year":"2015","unstructured":"Walch G, Vezeridis PS, Boileau P, Deransart P, Chaoui J (2015) Three-dimensional planning and use of patient-specific guides improve glenoid component position: an in vitro study. J Shoulder Elbow Surg 24:302\u2013309. https:\/\/doi.org\/10.1016\/j.jse.2014.05.029","journal-title":"J Shoulder Elbow Surg"}],"container-title":["International Journal of Computer Assisted Radiology and Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11548-025-03542-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11548-025-03542-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11548-025-03542-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,30]],"date-time":"2026-03-30T10:21:15Z","timestamp":1774866075000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11548-025-03542-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,5]]},"references-count":31,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["3542"],"URL":"https:\/\/doi.org\/10.1007\/s11548-025-03542-7","relation":{},"ISSN":["1861-6429"],"issn-type":[{"value":"1861-6429","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,5]]},"assertion":[{"value":"3 April 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 October 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"5 November 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Author Matthew T Bramlet is a co-founder of Enduvo, the VR software platform used in this research effort. Authors Eliot Bethke, Bradley P Sutton, James L Evans, Ainsley Hanner, Ashley Tran, Brendan O\u2019Rourke, Nina Soofi, and Jennifer R Amos declare they have no conflicts of interest","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"This research study was approved by the Institutional Review Board (IRB) at Order of Saint Francis Healthcare (OSF). Patient data\u00a0were acquired\u00a0through\u00a0IRB\u00a0#2021766\u20135 last\u00a0approved\u00a08\u00a0March 2024\u00a0by\u00a0University\u00a0of\u00a0Illinois\u00a0College\u00a0of\u00a0Medicine\u00a0Peoria. The study protocol included considerations for informed consent, data privacy and security, the analytical methods employed, and ethical considerations.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval"}}]}}