Virtual Reality in Neonatal Ductal Stenting: A New Era in Preprocedural Planning for Ductus Arteriosus Stenting in Complex Congenital Heart Defects with Duct-Dependent Pulmonary Circulation

Ductus arteriosus (DA) stenting is a well-established interventional alternative to surgical systemic-to-pulmonary shunts in neonates with congenital heart defects and ductal-dependent pulmonary circulation (DDPC). While it avoids sternotomy and cardiopulmonary bypass, the procedure remains technically demanding, especially in cases involving tortuous or misaligned ductal anatomy. Such anatomical complexity is associated with increased procedural difficulty and a higher rate of reinterventions. Although echocardiography, computed tomography (CT), and angiography remain key imaging modalities, they may be limited in providing comprehensive spatial context. Virtual reality (VR) has recently emerged as a promising tool that enables interactive 3D visualisation of cardiovascular structures and may enhance preprocedural assessment. This study aimed to evaluate the feasibility and potential benefits of CT-derived VR-based 3D modelling for preprocedural planning in neonates undergoing DA stenting for DDPC. The study compared VR-derived anatomical and procedural assessments with conventional angiographic imaging. Between March 2021 and August 2023, six neonates with DDPC underwent preprocedural contrast-enhanced CT and were included in this single-centre retrospective study. Three additional patients referred for DA stenting without CT were excluded. Dedicated VR software (VMersive, Poland) was used to automatically generate interactive 3D models from CT datasets without manual segmentation. The models were evaluated using immersive VR headsets and controller-based tools for precise anatomical assessment. DA morphology, tortuosity classification, total ductal length [L1], straight-line distance [L2], curvature index (CI), optimal fluoroscopic projection, and vascular access were analysed in VR and compared with angiographic data. Paired t-tests were used for statistical comparison, with significance set at p < 0.05. All six VR models were successfully created in under 5 min. Morphological and tortuosity classification: VR-based assessments were consistent with angiographic classification (Type I-III), confirming reliability. Length and curvature: VR-derived [L1] values were significantly longer than angiographic measurements (mean: 28.93 mm vs. 24.14 mm; p = 0.038). Curvature index was significantly higher in VR (mean: 0.46 vs. 0.29; p < 0.001), especially in Type III ducts, suggesting that angiography underestimates vascular tortuosity. Projection planning: Median angular deviation between VR-recommended and final procedural projections was 12° (range: 6-30°, p = 0.259). In cases requiring multiple contrast injections, final projections closely matched VR suggestions, indicating VR's potential to reduce radiation exposure and procedural time. Vascular access: VR-predicted access matched initial operator choice in 3/6 cases (50%), rising to 5/6 (83%) when reinterventions were included. Adjacent structures: VR allowed simultaneous visualisation of DA and adjacent thoracic structures. In patients with anomalous pulmonary venous return, VR clarified spatial relationships and potential compression risk. Additionally, in one case, a persistent vertical vein was identified, guiding a rare, combined intervention strategy. VR-based 3D modelling from CT data are a feasible and effective tool for preprocedural planning in DA stenting. It provides accurate spatial insight into ductal anatomy, curvature, projection alignment, and access routes. VR enhances anatomical understanding, supports multidisciplinary planning, and may reduce procedural uncertainty, particularly in complex neonatal interventions.