{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T03:48:00Z","timestamp":1781236080655,"version":"3.54.1"},"reference-count":35,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,12]],"date-time":"2025-11-12T00:00:00Z","timestamp":1762905600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Virtual Real."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Mixed reality (MR) technologies, such as those integrating Unity and Microsoft HoloLens 2, hold promises for enhancing non-coronary interventions in interventional cardiology by providing real-time 3D visualizations, multi-user collaboration, and gesture-based interactions. However, barriers to clinical adoption include insufficient validation of performance, usability, and workflow integration, aligning with the Research Topic on transforming medicine through extended reality (XR) via robust technologies, education, and ethical considerations. This study addresses these gaps by developing and rigorously evaluating an MR system for procedures like transcatheter valve replacements and atrial septal defect repairs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The system was built using Unity with modifications to the UnityVolumeRendering plugin for Digital Imaging and Communications in Medicine (DICOM) data processing and volume rendering, Mixed Reality Toolkit (MRTK) for user interactions, and Photon Unity Networking (PUN2) for multi-user synchronization. Validation involved technical performance metrics (e.g., frame rate, latency), measured via Unity Profiler and Wireshark during stress tests. Usability was assessed using the System Usability Scale (SUS) and NASA Task Load Index (NASA-TLX), as well as through task-based trials. Workflow integration was evaluated in a simulated cath-lab setting with six cardiologists, focusing on calibration times and responses to a custom questionnaire. Statistical analysis included means \u00b1 standard deviation (SD) and 95% confidence intervals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Technical benchmarks showed frame rates of 59.6 \u00b1 0.7 fps for medium datasets, local latency of 14.3 \u00b1 0.5\u00a0ms (95% CI: 14.1\u201314.5\u00a0ms), and multi-user latency of 26.9 \u00b1 12.3\u00a0ms (95% CI: 23.3\u201330.5\u00a0ms), with 91% gesture recognition accuracy. Usability yielded a SUS score of 77.5 \u00b1 3.8 and NASA-TLX of 37 \u00b1 7, with task completion times under 60\u00a0s. Workflow metrics indicated 38\u00a0s calibration and high communication benefits (4.5 \u00b1 0.2 on a 1\u20135 scale).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This validated MR solution demonstrates feasibility for precise, collaborative cardiac interventions, paving the way for broader XR adoption in medicine while addressing educational and ethical integration challenges.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/frvir.2025.1690439","type":"journal-article","created":{"date-parts":[[2025,11,12]],"date-time":"2025-11-12T06:33:14Z","timestamp":1762929194000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Design and validation of a mixed reality workflow for structural cardiac procedures in interventional cardiology"],"prefix":"10.3389","volume":"6","author":[{"given":"Jan","family":"Hecko","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Precek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaroslav","family":"Januska","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miroslav","family":"Hudec","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katerina","family":"Barnova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martina","family":"Palickova-Mikolasova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matej","family":"Pekar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan","family":"Chovancik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Libor","family":"Sknouril","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Otakar","family":"Jiravsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,11,12]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1007\/s10554-024-03250-8","article-title":"Augmented reality three-dimensional visualization of fusion imaging during left atrial appendage closure","volume":"41","author":"Allen","year":"2025","journal-title":"Int. J. Cardiovasc Imaging"},{"key":"B2","doi-asserted-by":"publisher","first-page":"4368","DOI":"10.3390\/jcm13154368","article-title":"Application of mixed\/augmented reality in interventional cardiology","volume":"13","author":"Annabestani","year":"2024","journal-title":"J. Clin. Med."},{"key":"B3","doi-asserted-by":"publisher","first-page":"840","DOI":"10.14569\/ijacsa.2021.0120698","article-title":"Comprehensive analysis of augmented reality technology in modern healthcare system","volume":"12","author":"Ara","year":"2021","journal-title":"Int. J. Adv. Comput. Sci. Appl."},{"key":"B4","doi-asserted-by":"publisher","first-page":"e29080","DOI":"10.2196\/29080","article-title":"Augmented, mixed, and virtual reality-based head-mounted devices for medical education: systematic review","volume":"9","author":"Barteit","year":"2021","journal-title":"JMIR Serious Games"},{"key":"B5","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.jcct.2018.10.027","article-title":"Mixed reality holograms for heart surgery planning: initial experience","volume":"13","author":"Brun","year":"2019","journal-title":"J. Cardiovasc Comput. Tomogr."},{"key":"B6","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1007\/978-3-030-33128-3_1","article-title":"Deep learning in medical image analysis","volume":"1213","author":"Chan","year":"2020","journal-title":"Adv. Exp. Med. Biol."},{"key":"B7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2018\/5435097","article-title":"How to build a patient-specific hybrid simulator for orthopaedic open surgery: benefits and limits of mixed-reality using the microsoft HoloLens","volume":"2018","author":"Condino","year":"2018","journal-title":"J. Healthc. Eng."},{"key":"B8","doi-asserted-by":"publisher","first-page":"151","DOI":"10.3390\/jimaging7080151","article-title":"A virtual reality system for improved image-based planning of complex cardiac procedures","volume":"7","author":"Deng","year":"2021","journal-title":"J. Imaging"},{"key":"B9","doi-asserted-by":"publisher","first-page":"949360","DOI":"10.3389\/frvir.2022.949360","article-title":"Real-time 3D scans of cardiac surgery using a single optical-see-through head-mounted display in a Mobile setup","volume":"3","author":"Dewitz","year":"2022","journal-title":"Front. Virtual Real"},{"key":"B10","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1007\/s10916-016-0459-8","article-title":"A review of simulators with haptic devices for medical training","volume":"40","author":"Escobar-Castillejos","year":"2016","journal-title":"J. Med. Syst."},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1007\/s11547-025-02001-2","article-title":"Extended reality in radiology: a review of virtual reality, augmented reality, and mixed reality applications","author":"Ferreira-Junior","year":"2025","journal-title":"Radiol. Med."},{"key":"B12","doi-asserted-by":"publisher","first-page":"274","DOI":"10.3390\/jimaging7120274","article-title":"A system for real-time, online mixed-reality visualization of cardiac magnetic resonance images","volume":"7","author":"Franson","year":"2021","journal-title":"J. Imaging"},{"key":"B13","first-page":"233","article-title":"Augmented reality for interventional procedures","volume-title":"Augmented environments for computer-assisted interventions","author":"Gupta","year":"2020"},{"key":"B14","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1109\/TVCG.2023.3247058","article-title":"Understanding, addressing, and analysing AR\/VR ergonomics and fatigue: a systematic review","volume":"30","author":"Hirzle","year":"2024","journal-title":"IEEE Trans. Vis. Comput. Graph"},{"key":"B15","doi-asserted-by":"publisher","first-page":"28784","DOI":"10.1038\/s41598-024-76384-z","article-title":"Real-time 3D catheter tracking in extended reality for cardiac interventions training","volume":"14","author":"Hosseini","year":"2024","journal-title":"Sci. Rep."},{"key":"B16","doi-asserted-by":"publisher","first-page":"12","DOI":"10.6224\/JN.000078","article-title":"VR and AR applications in medical practice and education","volume":"64","author":"Hsieh","year":"2017","journal-title":"Hu Li Za Zhi"},{"key":"B17","doi-asserted-by":"publisher","first-page":"e0205188","DOI":"10.1371\/journal.pone.0205188","article-title":"Three-dimensional holographic visualization of high-resolution myocardial scar on HoloLens","volume":"13","author":"Jang","year":"2018","journal-title":"PLoS One"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1912","DOI":"10.1109\/TVCG.2015.2473855","article-title":"Resolving the vergence-accommodation conflict in head-mounted displays","volume":"22","author":"Kramida","year":"2016","journal-title":"IEEE Trans. Vis. Comput. Graph."},{"key":"B19","doi-asserted-by":"publisher","first-page":"1548","DOI":"10.3390\/biom12111548","article-title":"Clinical applications of mixed reality and 3D printing in congenital heart disease","volume":"12","author":"Lau","year":"2022","journal-title":"Biomolecules"},{"key":"B20","article-title":"UnityVolumeRendering (Version 1.2.0) [Software]","author":"Lavik","year":"2023","journal-title":"GitHub"},{"key":"B21","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1186\/s13018-022-03312-3","article-title":"Application of HoloLens-based augmented reality navigation technology in transforaminal endoscopy surgery","volume":"17","author":"Li","year":"2022","journal-title":"J. Orthop. Surg. Res."},{"key":"B22","doi-asserted-by":"publisher","first-page":"e45850","DOI":"10.2196\/45850","article-title":"Ethical artificial intelligence in digital healthcare: a systematic review","volume":"12","author":"Martinez-Millana","year":"2024","journal-title":"JMIR Med. Inf."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1356361","DOI":"10.3389\/fcvm.2024.1356361","article-title":"Clinical application of virtual reality in patients with cardiovascular disease: state of the art","volume":"11","author":"Micheluzzi","year":"2024","journal-title":"Front. Cardiovasc Med."},{"key":"B24","article-title":"Mixed Reality Toolkit (MRTK). (Version 2.7.2.0) [Software]","year":"2021","journal-title":"GitHub"},{"key":"B25","doi-asserted-by":"publisher","first-page":"e18637","DOI":"10.2196\/18637","article-title":"Augmented and mixed reality based image guidance for percutaneous coronary intervention: a systematic review","volume":"22","author":"Muangpoon","year":"2020","journal-title":"J. Med. Internet Res."},{"key":"B26","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1186\/s41747-017-0033-2","article-title":"Through the HoloLens\u2122 looking glass: augmented reality for extremity reconstruction surgery using 3D vascular models with perforating vessels","volume":"2","author":"Pratt","year":"2018","journal-title":"Eur. Radiol. Exp."},{"key":"B27","doi-asserted-by":"publisher","first-page":"1065","DOI":"10.1007\/s11548-018-1748-3","article-title":"Comparison of optical see-through head-mounted displays for surgical interventions with object-anchored 2D-display","volume":"13","author":"Qian","year":"2018","journal-title":"Int. J. Comput. Assist. Radiol. Surg."},{"key":"B28","doi-asserted-by":"publisher","first-page":"362","DOI":"10.1016\/j.inffus.2022.10.032","article-title":"Neuromorphic reinforcement learning with neuromodulation for medical image segmentation","volume":"91","author":"Ranjbarzadeh","year":"2023","journal-title":"Inf. Fusion"},{"key":"B29","doi-asserted-by":"publisher","first-page":"636","DOI":"10.3390\/app10020636","article-title":"A review on mixed reality: current trends, challenges and prospects","volume":"10","author":"Rokhsaritalemi","year":"2020","journal-title":"Appl. Sci."},{"key":"B30","doi-asserted-by":"publisher","first-page":"287","DOI":"10.1016\/j.athoracsur.2019.06.050","article-title":"Current and future applications of virtual, augmented, and mixed reality in cardiothoracic surgery","volume":"109","author":"Sadeghi","year":"2020","journal-title":"Ann. Thorac. Surg."},{"key":"B31","doi-asserted-by":"publisher","first-page":"1823","DOI":"10.1016\/j.jcin.2024.06.021","article-title":"Mixed reality in structural heart disease: a systematic review and meta-analysis","volume":"17","author":"Silva","year":"2024","journal-title":"JACC Cardiovasc Interv."},{"key":"B32","doi-asserted-by":"publisher","first-page":"160","DOI":"10.1016\/j.csbj.2024.02.024","article-title":"MiVitals\u2013 xed reality interface for monitoring: a HoloLens based prototype for healthcare practices","volume":"24","author":"Tanbeer","year":"2024","journal-title":"Comput. Struct. Biotechnol. J."},{"key":"B33","doi-asserted-by":"publisher","first-page":"456","DOI":"10.1109\/TMI.2024.3451234","article-title":"Real-time performance metrics for medical mixed reality: a standardization framework","volume":"44","author":"Wang","year":"2025","journal-title":"IEEE Trans. Med. Imaging"},{"key":"B34","doi-asserted-by":"publisher","first-page":"640","DOI":"10.1007\/s10278-010-9321-6","article-title":"Volume visualization: a technical overview with a focus on medical applications","volume":"24","author":"Zhang","year":"2011","journal-title":"J. Digit. Imaging"},{"key":"B35","doi-asserted-by":"publisher","first-page":"3311","DOI":"10.1093\/eurheartj\/ehad352","article-title":"Extended reality in cardiovascular medicine: a narrative review","volume":"44","author":"Zlahoda-Huzior","year":"2023","journal-title":"Eur. Heart J."}],"container-title":["Frontiers in Virtual Reality"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frvir.2025.1690439\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,12]],"date-time":"2025-11-12T06:33:17Z","timestamp":1762929197000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frvir.2025.1690439\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,12]]},"references-count":35,"alternative-id":["10.3389\/frvir.2025.1690439"],"URL":"https:\/\/doi.org\/10.3389\/frvir.2025.1690439","relation":{},"ISSN":["2673-4192"],"issn-type":[{"value":"2673-4192","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,12]]},"article-number":"1690439"}}