Immersive training in cardiology : focus on coronary obstructions surgery process with virtual reality

Academic Year: 2024-2025

REPUBLIC OF BENIN MINISTRY OF HIGHER EDUCATION AND SCIENTIFIC RESEARCH UNIVERSITY OF ABOMEY-CALAVI INSTITUTE OF TRAINING AND RESEARCH IN COMPUTER SCIENCE BP 526 Cotonou Tel: [phone] http://www.ifri-uac.net Courriel : [e-mail]

THESIS

for obtaining a

Bachelor's Degree in Computer Science
Option: Internet and Multimedia

Presented by :

Adéfêmi Marie-Adelphe AGUESSY

Immersive training in cardiology:

focus on coronary obstructions surgery process with Virtual

Reality

Under the supervision of :

Engineer Lémec AHOUANDJINOU

Examination committee :

Maurice COMLAN	PhD (Associate Professor)	UAC	Chair
Linuse TIKPON	Engineer	UAC	Examiner
Lémec AHOUANDJINOU	Engineer	UAC	Rapporteur

i

Summary

Dedication ii

Acknowledgements iii

Résumé iv

Abstract iv

List of Figures vi

List of Tables vii

List of Acronyms viii

Glossary ix

Introduction 2

1 State of Art 4

2 Conception and technical choices 18

3 Presentation of the solution and discussions 26

Conclusion 33

Bibliography 34

Webography 35

Contents 39

Dedication

ii

To

My father, Adéchokpè Philippe AGUESSY My mother, Gisèle METONWANOU

iii

Acknowledgements

We express our sincere gratitude to all those who, directly or indirectly, contributed to the completion of this work:

· God, our Creator, the Most Merciful, for granting us the health, strength, inspiration, and perseverance needed throughout this journey;

· Professor Eugène C. EZIN, Director of the Institute for Training and Research in Computer Science (IFRI), for his insightful advice and invaluable guidance throughout our undergraduate studies;

· Professor Gaston G. EDAH, Deputy Director of IFRI, for his continuous support during these three years of training;

· Our supervisor, Engineer Lémec AHOUANDJINOU, for his availability, rigor, and willingness to share his knowledge throughout the development of this project;

· Dr. Burçin ÜNAL, Head of Communication & Design Department at Alanya University, for her kind support and guidance during our exchange semester in Alanya;

· Dr Hugues DOGOU, Cardiologist at the Departmental University Hospital Center of Parakou, for his medical expertise;

· My younger brother, Déo-Gratias, for his constant and invaluable support;

· My seniors, Nicos HOUNVIO and Lazare FAGBOHOUN, for their emotional and technical support throughout our undergraduate studies;

· Mr. Parisius Dorian HOUESSOU, Dr. Gervais AFFOGNON, Dr. Adelphe ADAMBADJI and Mrs Eugenie HOUNGBO for their insightful technical advice and unwavering support;

· The administration and entire teaching staff of IFRI, for the quality of the training provided and their professional guidance;

· All the staff of IFRI, for their dedication to providing a conducive environment for learning and academic success;

· My family, friends, and all those who contributed through their support, encouragement, and inspiration to the success of this work;

· Finally, to all those who, through their daily commitment, inspire change, kindness, and progress in their communities.

iv

Abstract

Training in interventional cardiology is a major challenge in preparing medical students and young surgeons in Benin. Virtual reality (VR) is now emerging as an innovative technology which offers new educational opportunities in this field. Our study is part of this dynamic and proposes the design and development of an immersive VR software, called CardioTrain, dedicated to the simulation of coronary revascularisation procedures, in particular coronary angioplasty (PCI) and coronary artery bypass grafting (CABG). The software allows users to navigate a virtual operating theatre, manipulate surgical instruments and follow either a guided course or an autonomous mode. This approach promotes the gradual acquisition of technical skills, familiarisation with surgical equipment and a better understanding of the mechanisms involved in coronary obstructions. The solution was developed using tools such as Blender for 3D modelling, Unity for interactive implementation, and a customised SDK for VR integration. Tests confirmed the prototype's viability. Through this work, we believe we are making an innovative contribution to medical training in Benin by setting up an accessible, immersive and scalable tool that could ultimately enrich teaching practices and improve the quality of learning in interventional cardiology.

Key words: virtual reality, interventional cardiology, angioplasty, coronary artery bypass grafting, medical training.

Résumé

La formation en cardiologie interventionnelle représente un enjeu majeur pour la préparation des étudiants en médecine et des jeunes chirurgiens au Bénin. La réalité virtuelle (RV) s'impose au-jourd'hui comme une technologie innovante offrant de nouvelles perspectives pédagogiques dans ce domaine. Notre étude s'inscrit dans cette dynamique et propose la conception et le développement d'une application immersive en RV, nommée CardioTrain, dédiée à la simulation des interventions de revascularisation coronarienne, notamment l'angioplastie coronaire (PCI) et le pontage aorto-coronarien (CABG). L'application permet à l'utilisateur d'évoluer dans un bloc opératoire virtuel, de manipuler des instruments chirurgicaux et de suivre soit un parcours guidé, soit un mode autonome. Cette approche favorise l'acquisition progressive des compétences techniques, la familiarisation avec le matériel opératoire et une meilleure compréhension des mécanismes liés aux obstructions coronaires. Le développement de la solution s'est appuyé sur des outils tels que Blender pour la modélisation 3D, Unity pour l'implémentation interactive et un SDK adapté pour l'intégration VR. Les tests réalisés ont confirmé la viabilité du prototype. À travers ce travail, nous estimons apporter une contribution innovante dans le domaine de la formation médicale au Bénin, en proposant un outil accessible, immersif et évolutif, qui pourrait à terme enrichir la pratique pédagogique et améliorer la qualité de l'apprentissage en cardiologie interventionnelle.

Mots clés : réalité virtuelle, cardiologie interventionnelle, angioplastie, pontage aorto-coronarien, formation médicale.

vi

List of Figures

1.1	Coronary arteries		5	1.2
Touch Surgery (by Medtronic)	10		1.3
WebSurg home interface	10		1.4
Surgery Squad home interface	11		1.5
VCSim3 complete set-up including the simulator software running on the laptop, VSP haptic device, fluoroscopic view console, balloon inflation device, and contrast injec-
tion syringe	14		1.6
Screen captures from the virtual reality-extracorporeal circulation (VR-ECC) simulator, featuring from left-to-right: adjustment of the venous occluder (A), removal of the a clamp from the arterial line (B), an overview of the heart-lung machine (C), and the
menu system by which users navigate through the simulation (D).	15		1.7
home page of the official vCathlab website	15		1.8
Image courtesy of Osso VR. 16			2.1
Use case diagram	19		2.2
Sequence diagram for the use case "Simulate surgery on an obstructed heart"	20		2.3
Operating room design in Blender	22		2.4
Using the Unity3D engine to create the VR experience	22		2.5
Script for animating the user's hands written in Visual Studio 2017	23		2.6
Adobe Illustrator interface screenshot	24		3.1
CardioTrain Logo	26		3.2
CardioTrain Color Palette	27		3.3
CardioTrain logo variations	28		3.4
A few examples of the logo in use	28		3.5
Home interface	29		3.6
Selecting and choosing an instrument	29		3.7
Assisted CABG	30		3.8
some 3D operating room exploration screenshots	30		3.9
some 3D hearts exploration screenshots	31

List of Tables

vii

1.1 Comparison of VR Solutions for Cardiology Training 16

viii

List of Acronyms

AR :

Augmented Reality 11, 22, 23,

CABG :

Coronary Artery Bypass Grafting 7, 9, 18, 32,

CAD:

Coronary Artery Disease 4-6,

CardioTrain :

A platform that supports practical training in the treatment of coronary obstructions iv, 26-28,

CVDs :

Cardiovascular diseases 4,

MR :

Mixed Reality 11,

NSTEMI :

Non-ST-Elevation Myocardial Infarction 6,

PCI :

Percutaneous Coronary Intervention 6, 7, 18, 32,

STEMI:

ST-Elevation Myocardial Infarction 6,

UML :

Unified Modeling Language 19,

VR :

Virtual Reality iv, vii, 4, 12-17, 19, 20, 22-25, 32, 39,

ix

Glossary

AR : Immersive technology which overlays digital content onto the

real-world environment. viii

CABG : also known as coronary bypass surgery, it's a surgical procedure

that restores normal blood flow to the heart by creating new pathways around narrowed or blocked coronary arteries. viii

CAD: common type of heart disease which affects the main blood ves-
sels that supply blood to the heart, called the coronary arteries. viii

CardioTrain : This is the name of our virtual reality software that supports practical training in the treatment of coronary obstructions. viii

CVDs : are a group of disorders of the heart and blood vessels and in-
clude coronary heart disease, cerebrovascular disease, rheumatic heart disease and other conditions. viii

MR : Immersive technology which combines real and virtual environ-

ments with real-time interaction between physical and digital objects.. viii

NSTEMI : It's a type of heart attack where a coronary artery is partially

blocked, reducing but not completely cutting off the blood supply to part of the heart muscle. viii

STEMI: It's a severe type of heart attack where a major coronary artery

is completely blocked, cutting off blood supply to a significant portion of the heart muscle. viii

UML : It is a pictogram-based graphical modelling language designed

as a standardised method of visualisation in the fields of software development and object-oriented design. viii

Glossary Glossary

1

VR : Immersive technology with a fully immersive environments where users are completely cut off from the physical world. viii

2

General introduction

Cardiovascular diseases (CVDs) are the leading cause of death globally, taking an estimated 17.9 million lives each year [10], particularly in developing countries. Among them, coronary artery disease, caused by coronary artery obstruction, represents a critical pathology that requires rapid and precise management. While cardiology education in medical training programs, including in Benin, provides students with solid knowledge, their first hands-on interventions often occur directly on human patients, a situation likely to generate stress and uncertainty during initial clinical procedures. To mitigate these challenges and provide a safer, more controlled learning environment, immersive technologies such as virtual reality have emerged as a promising solution. By recreating complex clinical environments in a safe, interactive, and reproducible way, virtual reality offers an ideal framework for progressive skill acquisition. This is the background to our project: to develop a virtual reality training tool dedicated to the acquisition of skills linked to the treatment of coronary obstructions.

Problem statement

The progressive acquisition of initial practical skills in cardiology, including in contexts such as Benin, represents a key stage before students perform their first real interventions on patients. In this context, immersive technologies offer promising opportunities to enrich this stage, which raises the following central question: how can an immersive virtual reality application be designed to effectively support the progressive development of cardiology students' practical competencies, particularly in the treatment of coronary artery disease?

Objectives

The general objective of this thesis is to develop an immersive virtual reality application designed to train healthcare professionals in the management of cardiovascular diseases, in particular coronary artery obstructions. The specific objectives of this thesis are:

· Provide an interactive environment for learning cardiac anatomy and medical procedures;

· Reinforce clinical skills through simulations based on real cases;

· Support medical decision-making between procedures such as coronary artery bypass grafting

Glossary Glossary

3

and revascularisation;

· Design a scalable software architecture that will enable the application to be extended to other medical specialities.

Methodology (briefly)

The methodology adopted combines theoretical research into cardiovascular disease and immersive technologies, with agile development of the application. It comprises the following stages:

· Documentary analysis and collection of pedagogical needs;

· Design of models and 3D modelling of anatomical elements;

· Integration into a virtual reality engine (Unity);

· Programming of interactions and clinical scenarios;

· Testing and adjustments

Structure of the document

This thesis is structured around three main chapters.

The first chapter lays the theoretical foundations for our study. It presents the medical context of coronary artery disease and the issues involved in training cardiology students to manage it. It also provides a critical analysis of existing solutions, highlighting their advantages and limitations.

The second chapter is devoted to the design of the system developed. It describes the technical choices made and uses UML modeling to illustrate the main interactions through use case and sequence diagrams. The use of tools such as Unity and Blender is also justified, in view of the project's educational and immersive objectives.

Finally, the third chapter outlines the results obtained from implementing the system, while highlighting the difficulties encountered. It concludes with an outlook on possible improvements and future developments for the project.

4

Chapter1

State of Art

Introduction

In order to lay the theoretical and scientific foundations for our work, it is essential to examine the research and solutions already developed in similar fields. This chapter takes this approach by proposing an in-depth analysis of what already exists, with the aim of placing our project in its academic, medical and technological context. We begin by presenting the key concepts relating to cardiovascular disease, with particular emphasis on coronary artery disease, and the issues involved in training cardiology students. We will then explore the contribution of immersive technologies, in particular virtual reality, to medical learning. Particular attention will be paid to existing applications of VR in cardiology, in order to identify advances, shortcomings and future prospects. This review will identify the foundations on which our approach is based, while justifying the relevance of the proposed solution to improving specialized medical training.

1.1 Coronary artery diseases

1.1.1 Overview

Cardiovascular diseases (CVDs) are a group of troubles affecting the heart and blood vessels. They include conditions such as coronary heart disease, cerebrovascular disease, rheumatic heart disease, and others [10].

Among these, coronary artery disease (CAD) is one of the most common and serious forms, and remains a major cause of morbidity and mortality worldwide. Coronary artery disease occurs when the coronary arteries, which supply oxygen-rich blood to the heart muscle, become narrowed or blocked. This is typically the result of atherosclerosis, a process characterized by the accumulation of fatty deposits (plaques) on the inner walls of the arteries.

Over time, these plaques harden and restrict blood flow to the heart. If a plaque ruptures, it can cause a blood clot, leading to a heart attack [9].

[9] The development of CAD is influenced by modifiable lifestyle factors such as smoking, exces-

Chapter 1. State of Art 1.1. Coronary artery diseases

Figure 1.1: Coronary arteries

5

sive alcohol intake, poor diet, physical inactivity, and chronic stress, as well as medical conditions including type 2 diabetes, hypertension, and chronic kidney disease. Genetics and aging also contribute, highlighting the importance of prevention and early detection.

Symptoms of CAD often appear gradually and can be subtle. Typical signs include angina (chest pressure or pain), shortness of breath, fatigue, dizziness, cold sweats, or nausea. Symptom presentation can vary by sex, with men often exhibiting classic chest pain, while women may experience atypical signs such as back or jaw discomfort, sleep disturbances, or anxiety. This variability underscores the need for advanced training tools capable of simulating diverse clinical scenarios to improve diagnosis and treatment skills.

1.1.2 Coronary artery disease's treatments

Treatment of coronary artery disease (CAD) aims to relieve symptoms, slow or reverse disease progression, and reduce the risk of heart attacks and death. The therapeutic approach often depends on the severity of the blockage, the presence of symptoms, and the overall health status of the patient.

· Lifestyle and medical management:

In early or moderate stages, CAD may be managed through non-invasive methods, including:

- Lifestyle modifications: Patients are advised to stop smoking, reduce alcohol intake, adopt a healthy diet (e.g., low in saturated fats and sodium), exercise regularly, and try to manage stress.

- Pharmacological treatments: they include statins to lower cholesterol, beta-blockers to reduce heart rate and blood pressure, antiplatelet agents such as aspirin to prevent clot formation, ACE inhibitors and calcium channel blockers for blood pressure control, among others.

These treatments are usually the first line of defense and may significantly improve quality of life and prognosis.

· Chapter 1. State of Art 1.1. Coronary artery diseases

6

Interventional procedures

When medical treatment is insufficient or significant arterial blockage is present, more invasive procedures may be necessary. The choice of procedure depends on the individual case and its severity, aiming to achieve the best possible patient outcome.The most common procedures include:

- Percutaneous Coronary Intervention (PCI)

Also known as angioplasty, Percutaneous Coronary Intervention (PCI) is a minimally invasive procedure to restore blood flow in arteries narrowed or blocked by atherosclerotic plaque. During the procedure, a flexible catheter is carefully inserted through the groin or wrist and guided to the heart. Once at the blockage, a small balloon is inflated to widen the artery, and in most cases, a stent is then placed to keep the artery open.

PCI is a cornerstone of modern cardiology, indicated in acute cases like STEMI as an emergency reperfusion strategy, in high-risk NSTEMI or unstable angina patients, and in chronic CAD when symptoms persist despite optimal medical therapy or when significant multi-vessel or left main disease is present.

Instruments and medical equipment used

The setup for PCI requires specialized lab infrastructure and a comprehensive arsenal of

instruments to safely treat coronary artery disease. We can mention [18]:

* Operating table;

* Catheters (guide catheters, balloon catheters and aspiration catheters);

* Stents ;

* Contrast dye;

* Guidewires ;

* Fluoroscopy and imaging equipment called angiography suite ( a C-arm X-ray ma-

chine or biplane imaging system, digital monitors for live image display, radiation

protection systems and integrated control consoles for the interventional team);

* Pressure transducers and hemodynamic monitors;

* Sheaths and introducers;

* Cardiac defibrillator and emergency resuscitation equipment;

* Patient monitoring system (ECG, pulse oximeter, etc.) ;

Risks, complications, and how they are managed

Although Percutaneous Coronary Intervention (PCI) is generally safe and routine, it carries some risks typical of invasive procedures. Most complications are rare, but awareness is crucial for clinical practice and understanding patient outcomes. Common risks include: * Bleeding or hematoma at the catheter insertion site, especially with femoral access. That's why careful post-procedure monitoring is essential. Manual compression or vascular closure devices are often used to prevent complications.

* Allergic reactions to the contrast dye can occur, particularly in patients with a history of allergies or kidney issues. In such cases, premedication or low-osmolar contrast agents are usually recommended.

Chapter 1. State of Art 1.1. Coronary artery diseases

7

* Vascular injuries, like arterial dissection or perforation, are rare but serious. These may require immediate endovascular repair or, in extreme cases, emergency surgery.

* Arrhythmias (irregular heartbeats) might happen during the procedure when instruments pass through the coronary arteries. Most of the time, they're brief and managed with medications or temporary pacing if needed.

* There's also a chance of restenosis (artery narrowing again) or heart attack, but the use of drug-eluting stents and dual antiplatelet therapy (DAPT) has significantly reduced this risk over time.

In real-life practice, managing complications depends on a skilled medical team, close monitoring, and good planning before the procedure. Overall, the benefits of PCI clearly outweigh the risks ,especially for patients with severe angina or acute heart attacks.

- Coronary Artery Bypass Grafting (CABG)

Coronary Artery Bypass Grafting (CABG) is a major heart surgery with the same aim as the PCI defined above: to treat coronary obstructions.

However,its technique is special: to «bypass» the blocked arteries. Surgeons take a healthy blood vessel,often from the patient's leg (saphenous vein) or chest (mammary artery) and graft it onto the heart to reroute blood flow around the blockage. It's like building a new road when the highway is closed.

CABG becomes necessary when medications and lifestyle changes aren't enough or angioplasty (with stents) isn't a good option or the blockages are too many or too complex.

Patients who benefit most from CABG usually have multiple blocked arteries or diabetes or reduced heart function (especially in the left ventricle).

Instruments and medical equipment used

Coronary Artery Bypass Grafting (CABG) relies on specialized instruments and machines that support every stage of the complex surgery, from opening the chest to maintaining circulation and performing precise vessel grafting. [20]

* Operation table, pressure transducers, hemodynamic monitors and patient monitoring system (ECG, Pulse oximeter, etc.) as for PCI ;

* Heart-Lung machine (Cardiopulmonary Bypass Machine);

* Dissection instruments ( scissors, forceps, scalpels, sternal saws, and dissectors);

* Cannulae (arterial and venous tubes);

* Vascular grafts;

* Surgical retractors;

* Surgical sutures and needle holders; * Electrocautery devices;

* Perfusion systems;

* Suction devices;

* Aortic punch and clamp [21] ;

Chapter 1. State of Art 1.2. Cardiology training issues

8

Risks, complications, and how they are managed [23]

Even though Coronary Artery Bypass Grafting is a common and life-saving surgery, it's important to understand that it comes with its share of risks and possible complications. Some of the main risks include infections at the incision site, bleeding during or after surgery, and issues related to anesthesia. There's also a risk of irregular heart rhythms, like atrial fibrillation, which can happen after surgery and may require medication or further treatment.

More serious but less common complications can involve stroke, heart attack, kidney problems, or lung issues. The surgical team is always prepared to monitor for these and manage them quickly. For example, antibiotics are given to prevent infection, and blood thinners may be used to reduce the risk of clots.

Doctors also closely watch the patient's vital signs and use advanced monitoring to catch any problems early. The recovery period includes careful follow-up to ensure the heart is healing well and the new grafts remain open.

1.2 Cardiology training issues

1.2.1 Current methods of training cardiology students with contextual focus on Benin

In Benin, most of the cardiology education for future specialists begins at the large Faculty of Health Sciences ( FSS ) of the University of Abomey Calavi (UAC).

The FSS offers the degree called "Diplôme d'Études Spécialisées des Maladies du Coeur et des Vaisseaux"[44, 45], which includes theoretical lectures, classroom case studies, and occasional practical exposure in affiliated hospitals such as Cotonou's National University Hospital Hubert Koutoukou Maga.

Clinical rotations are mostly done at teaching hospitals like the cardiology unit of the University Hospital in Cotonou, where students observe procedures like ECGs, diagnostic angiographies, or rounds in consultation and emergency services.[24] Unfortunately, due to limited infrastructure and a high patient to student ratio, hands-on opportunities are rare. The learning remains largely observation-based, with medical interns and residents performing most interventions. According to some of those students,theoretical knowledge is reinforced through seminars, lectures, and case discussions led by senior cardiologists. However, advanced simulation tools or structured procedural training labs are largely absent. The reliance on traditional pedagogy reflects broader resource constraints in the health sector and highlights a gap between classroom learning and actual clinical competence. And in the end, their first real experience still happens directly on a human patient.

1.2.2 Limitations of the theoretical approach alone

In medical training,especially in cardiology,theoretical knowledge is indispensable. However, it has a critical flaw: it prepares students to know, but not necessarily to do. In Benin, as in many countries with limited access to simulation technologies,the only option left is to «learn on the job», with all the risks that entails. Then, students often move directly from theory to real-life practice... on real patients. This situation raises both educational and ethical concerns.

Chapter 1. State of Art 1.2. Cardiology training issues

9

A student might learn, in theory, how to manage a myocardial infarction or perform an angioplasty, but their first real attempt often takes place on an actual patient. There is no buffer, no rehearsal stage. Classrooms teach equations and diagrams but not stress, uncertainty, or the weight of holding a catheter when someone's life is at stake.

The result?

· Students feel unprepared and insecure, especially in high-stakes procedures like those found in interventional cardiology.

· Patients, often unaware, become the first practice ground, exposing them to potential risks.

· Instructors struggle to bridge the gap between abstract knowledge and real-time performance under pressure for their students.

This theory-practice gap is not a new problem. It has been widely documented in international research. A study published in BMC Medical Education (2020) highlights that students without early exposure to simulation-based practice experience higher anxiety levels and reduced performance in clinical situations. [25, 26]

1.2.3 Complication and error rates in initial coronary surgery experiences

Several studies have documented measurable differences in operative performance and complication rates during a surgeon's first procedures, particularly in coronary artery bypass grafting (CABG).A retrospective study conducted between 2008 and 2014 analyzed 1,668 CABG cases performed by 21 surgical residents, each of whom had performed between 32 and 101 procedures under supervision. In their first 30 cases, residents demonstrated a significantly longer operative time, an average of 29.7 minutes longer than experienced surgeons. This delay was attributed primarily to longer incision-to-bypass times (+13 minutes) and extended closure durations. Importantly, these extended operative times did not correspond with higher 30-day mortality rates or major postoperative complications. [27].

In a separate analysis using data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, 1,195 robotic-assisted CABG procedures were evaluated across 114 surgeons with no prior experience in robotic techniques. The first 10 cases for each surgeon revealed:

· A conversion rate drop from 7.7% to 2.5%,

· A major morbidity or mortality rate decline from 21.7% to 12.9%,

· A procedural success increase from 72.9% to 85.3% [28]

These findings confirm that the initial learning curve in coronary surgery is associated with quantifiable performance differences, particularly during the earliest procedures, despite adequate supervision and safety measures.

1.2.4 Existing digital solutions (Excluding immersive technologies)

Various non-immersive digital tools, including mobile apps, web platforms, and simulation software, are used to train healthcare professionals in cardiology, enhancing knowledge and clinical decision-making skills.

· Chapter 1. State of Art 1.2. Cardiology training issues

10

Touch Surgery (by Medtronic):

Touch Surgery is a mobile surgical simulation app used globally to teach step-by-step procedures in various specialties, including cardiovascular surgery. It offers interactive, gamified modules that guide learners through virtual procedures using touchscreen gestures and 3D animations.

Figure 1.2: Touch Surgery (by Medtronic)

· WebSurg :

WebSurg is a free online surgical training platform developed by the IRCAD (Research Institute against Digestive Cancer). It provides a comprehensive library of educational resources, including high-definition surgical videos, expert commentaries, clinical case discussions, and theoretical modules covering over 100 surgical procedures and specialties.It supports multiple languages and is accessible worldwide, making it a valuable tool, especially for professionals in regions with limited access to in-person surgical training.

Figure 1.3: WebSurg home interface

· Surgery Squad:

Surgery Squad is an interactive web-based platform that allows users to virtually perform various surgical procedures, such as coronary bypass, appendectomies, and knee replacements, through guided, step-by-step simulations. Designed primarily for educational outreach and

Chapter 1. State of Art 1.3. Immersive technologies in the medical field

11

public engagement, it simplifies complex surgical processes and makes them accessible to non-experts.

Figure 1.4: Surgery Squad home interface

1.3 Immersive technologies in the medical field

Immersive technologies refer to digital systems designed to simulate reality or extend it, allowing users to experience environments that feel engaging, realistic, or entirely fabricated. These technologies create a sense of «being there», often through multisensory input,visual, auditory, and sometimes tactile making users feel mentally and physically involved in the experience. Their core objective is to blur the line between the physical and the digital world.[2] Several forms of immersive technologies exist, each with specific characteristics and applications:

· Virtual Reality (VR): Fully immersive environments where users are completely cut off from the physical world.

· Augmented Reality (AR): Overlays digital content onto the real-world environment.

· Mixed Reality (MR): Combines real and virtual environments with real-time interaction between physical and digital objects.

Each of these technologies has made significant advances in education, design, health, and entertainment. However, not all are equally mature or widely implemented.

1.3.1 Virtual Reality as a key immersive technology in medical training

While AR and MR are promising, Virtual Reality stands out today as the most established and widely adopted immersive tool in medical training. Its ability to simulate real-world procedures in a safe and controlled environment without risk to patients has made it a go-to modality for teaching anatomy, surgery, and complex decision-making. Its effectiveness relies on three core pillars: presence (feeling «there» in the virtual world), immersion (full sensory engagement), and interaction (manipulating

Chapter 1. State of Art 1.3. Immersive technologies in the medical field

12

virtual objects with immediate feedback), which together transform passive learners into active participants, enhancing procedural memory and reflex development.[30]

In addition, recent hardware improvements and decreasing costs have made virtual reality more accessible to universities, hospitals, and simulation centers around the world.

1.3.1.1 Types of Virtual Reality experiences in medical education

All VR systems are not created equal. In medical education, they are typically categorized into three main types, depending on their level of immersion and technological complexity:

· Non-Immersive VR which is desktop-based, and allows users to interact with 3D environments via a screen, keyboard, and mouse without full sensory immersion. Despite its limitations, it enables students to explore anatomy and simulate basic procedures.

· Semi-Immersive VR which uses large screens, projectors, or CAVE systems to provide partial immersion. It enhances spatial perception compared to non-immersive VR while still allowing real-world interaction. These setups are ideal for group training or large-scale visualizations.

· Fully Immersive VR which places users entirely inside a virtual environment using head-mounted displays (HMDs), motion tracking, and sometimes haptic feedback. Users' movements are mirrored in the simulation, allowing precise surgical gestures and emergency responses.

1.3.1.2 Tools and equipment in VR training

To ensure effective medical training through VR, a combination of specialized hardware and software is essential. These tools work together to replicate real-life medical scenarios as closely as possible:

· Head-Mounted Displays (HMDs)

These wearable devices display the virtual environment and track the user's head movements. Common models include Meta Quest 2 / Quest 3 , HTC Vive Pro and Pico Neo 3 / 4 .

· Motion controllers and hand tracking

Controllers enable interaction with virtual tools, such as scalpels or syringes. More advanced systems support hand tracking, allowing the user's hands to be visualized and used directly in the simulation. They are useful in suturing, palpation, or tool manipulation.

· Haptic feedback devices

These simulate tactile sensations like pressure, vibration, or resistance. Haptic gloves or instrument handles can recreate the feeling of cutting tissue, inserting needles, or stitching skin. Example: HaptiTouch or ImmersiveTouch provide physical feedback during simulated surgery.

1.3.1.3 Modalities of use in medical education

VR is transforming multiple facets of medical education, providing experiential learning in a controlled, repeatable, and safe environment. Below are key application areas:

· Skills training: VR allows repeated practice of clinical techniques such as incision making, endoscopy, cardiopulmonary resuscitation (CPR) or suturing without using real patients or cadavers.

·

Chapter 1. State of Art 1.4. VR applications in cardiology

13

Surgical simulation: Step-by-step rehearsal of complex procedures like laparoscopy, arthroscopy, or spinal fusion. Users receive feedback on precision, speed, and safety.It's used by residents to supplement operating room training.

· Anatomy education: 3D exploration of body systems with the ability to rotate, dissect, or zoom into structures in ways that static atlases cannot offer.

· Clinical decision-making: Virtual patients with diverse symptoms can be examined, diagnosed, and treated in real-time. This helps students practice diagnostic reasoning, triage, and treatment planning.

· Empathy and communication training: Some VR experiences place learners in the shoes of patients such as those with dementia, vision loss, or chronic pain to foster empathy and improve communication.

· Patient education: VR is also used to help patients understand their upcoming procedures, reducing anxiety and improving compliance.

· Case study: Stanford's Immersive Learning Initiative integrated VR surgical training into its curriculum and reported that learners demonstrated: [31]

- Increased procedural confidence

- Improved knowledge retention

- More accurate performance under pressure

1.3.2 Pedagogical benefits and cognitive impacts of immersive technologies

Immersive technologies, especially VR, enhance medical education by transforming how learners acquire, retain, and apply knowledge. This section highlights their contributions through both pedagogical frameworks and insights from cognitive science, offering controlled, responsive, and adaptive environments for high-stakes learning.

These technologies enhance engagement and active learning in line with constructivist learning the-ory[3], improve retention and knowledge transfer [32], reduce cognitive load while fostering spatial understanding [33], enable learners to receive immediate feedback and learn from errors, support social and clinical reasoning through emotional and empathy training [34], and strengthen self-efficacy and confidence before real clinical practice [35], among other benefits.

1.4 VR applications in cardiology

1.4.1 Existing projects and tools in cardiology training

The use of virtual reality in cardiology has gained momentum in recent years, offering new ways to teach, simulate, and understand complex cardiac procedures. Several VR-based tools and initiatives are already being used or developed for training medical professionals in cardiovascular medicine. Let's talk about some of these immersive solutions.

· Chapter 1. State of Art 1.4. VR applications in cardiology

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VCSim3 (Virtual Catheter Simulator)

VCSim3 is a virtual reality simulator designed for cardiovascular interventions, focusing on the manipulation of catheters and guidewires. Developed at Erasmus MC, it uses an inextensible Cosserat rod model to simulate the mechanical behavior of these tools with sub-millimetre accuracy. This allows trainee cardiologists to practice procedures like stent deployment and angioplasty in a safe, virtual environment. VCSim3 enhances surgical training by providing a risk-free alternative to traditional methods, eliminating ethical concerns and reducing costs associated with patient, animal, or cadaver use. Although still a prototype, it shows promising potential for medical training programs.

Figure 1.5: VCSim3 complete set-up including the simulator software running on the laptop, VSP haptic device, fluoroscopic view console, balloon inflation device, and contrast injection syringe

· VR-ECC Simulator (Extracorporeal Circulation Training)

The VR-ECC Simulator is an advanced virtual reality training tool designed specifically for perfusionists. It focuses on enhancing the skills required for extracorporeal circulation (ECC), a critical procedure used during cardiac surgeries to temporarily support the heart and lung functions. Developed with cutting-edge technology, including Unreal Engine 4 and Autodesk Maya, this simulator offers an immersive and interactive experience. It allows healthcare professionals to practice and refine their techniques in a safe, controlled virtual environment. The VR-ECC Simulator has been validated for its effectiveness and ease of use, making it an invaluable resource for both novice and experienced perfusionists in the medical field. [36]

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Figure 1.6: Screen captures from the virtual reality-extracorporeal circulation (VR-ECC) simulator, featuring from left-to-right: adjustment of the venous occluder (A), removal of the a clamp from the arterial line (B), an overview of the heart-lung machine (C), and the menu system by which users navigate through the simulation (D).

· vCathLab

vCathLab is an advanced medical simulation platform that uses Virtual Reality (VR) to provide immersive and interactive training for healthcare professionals, particularly in the field of interventional cardiology. It allows users to practice cardiac catheterization procedures in a realistic virtual environment, thereby enhancing their skills without the risks associated with real procedures on patients. The platform includes authoring tools to generate customized virtual patients and various clinical scenarios, facilitating comprehensive and adaptable training. [37]

Figure 1.7: home page of the official vCathlab website

· Osso VR - Cardiology Modules (with ACC collaboration)

Osso VR partnered with the American College of Cardiology (ACC) to develop immersive left atrial appendage occlusion (LAAO) training modules. Trainees don a VR headset (such as Meta Quest or Oculus Rift) and rehearse step-by-step procedural workflows, including imaging control, device manipulation, and live anatomy visualization, all within a repeatable virtual environment. [38]

Osso VR offers trial access for educators and learners; contact through their official site.

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Figure 1.8: Image courtesy of Osso VR.

1.4.2 Comparative analysis of existing solutions and benefits of our solution.

	VCSim3	VR-ECC Simulator	vCathLab		Osso VR	Accessible in Daily Life
No	No	Yes	Yes		Equipment Cost
High	High	Affordable	Affordable-High		Easy Setup
No	No	Yes	Yes		Ease of Learning
Difficult	Moderately Difficult	Moderate	Moderate		Offline Functionality
No	No	No	No		Treat Coronary Obstructions
No	No	Yes	Yes

Table 1.1: Comparison of VR Solutions for Cardiology Training

By analysing this table,we can notice that while several VR-based cardiology training tools such as VCSim3, VR-ECC Simulator, vCathLab, and Osso VR offer valuable functionalities, they also present notable limitations. Some lack offline access or daily usability, while others require significant financial investment or pose moderate learning difficulties. Furthermore, only a few provide focused training on coronary obstruction treatment. These observations highlight the need for more inclusive, accessible, and affordable solutions that respond effectively to the real needs of cardiology trainees and practitioners.

Our proposed solution addresses several gaps observed in existing tools. Designed to be accessible within the daily environment of medical learners, it combines affordability, ease of installation, and offline functionality. With a simplified user interface, it minimizes the time needed to get started. Most importantly, it specifically supports coronary obstruction training,a critical yet underrepresented component in current platforms. By focusing on inclusivity, practicality, and contextual relevance, our solution aims to democratize cardiology training in low-resource settings.

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Conclusion

Interventional cardiology is a demanding medical discipline requiring precise technical skills and real-time decision-making. Traditional training methods, while effective, often face challenges of cost, access, and standardization, particularly in low and middle income countries. In this context, virtual reality emerges as a valuable complementary tool for training healthcare professionals. It enables learners to visualize complex procedures in a risk-free, immersive environment particularly those involving the treatment of coronary obstructions, which require high precision and confidence. By simulating real-life coronary interventions, VR fosters deeper understanding, improves procedural memory, and enhances practitioner readiness before clinical exposure. This approach can significantly contribute to the democratization of specialized medical education by making high-quality, targeted training such as for coronary obstruction treatment more accessible, flexible, and context-relevant. The observations and gaps identified in this chapter provide a solid foundation for proposing a VR-based training solution tailored to the specific needs of interventional cardiology.

The following chapter will present our solution through its design and the various tools used to implement it.

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Chapter2

Conception and technical choices

Introduction

At the beginning of creating an application, it is necessary to formalize the preliminary steps of its development to make it more aligned with the client's needs. This chapter presents the various phases of modeling the proposed solution as well as the different tools and technologies used for its implementation.

2.1 Analysis and design

This phase consists of understanding the context of the application. It involves determining the functionalities and performance criteria that our application must fulfil.

2.1.1 Needs analysis

Functional needs

Functional needs are the system's functionalities, they represent the user's primary needs. Thus, through the solution, the user will be able to:

· Select and view a healthy heart, an obstructed heart, and/or the operating room and equipments in 3D ;

· Simulate assisted PCI or CABG on an obstructed heart;

· Simulate autonomous PCI or CABG on an obstructed heart; Once we have designed an administrator system, the administrator will be able to:

· Add or modify training modules;

· Update 3D models or clinical cases;

Non-functional needs

Non-functional needs are those that characterize the system. These are needs relating to performance and hardware type. The non-functional needs of the solution can be listed as follows:

·

Chapter 2. Conception and technical choices 2.1. Analysis and design

Comfortable VR experience (minimal eye strain and motion sickness);

· Attractive and user-friendly interfaces;

· Realistic and intuitive interactions;

· Smooth and stable performance (high frame rates, low latency, fluid animations);

· Immersive and visually accurate environment;

· Ergonomics and hardware compatibility;

2.1.2 Design

2.1.2.1 Technical design

We now enter the modelling phase. It is an essential part of large software projects and is also useful for medium-sized and even small projects. For this phase, we have opted for the UML (Unified Modeling Language) modelling language which is [39] is a standard modeling language that uses diagrams to help developers design, understand, and document software systems and business processes. In the following sections, we reprensent our system with both a use case diagram and a sequence diagram.

Use case diagram

The use case diagram in Figure 2.1 shows the different actions performed by the actors. An actor represents a person, process, or object outside the system that interacts with it.

Figure 2.1: Use case diagram

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Chapter 2. Conception and technical choices 2.1. Analysis and design

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Sequence diagram

The sequence diagram shows the interactions between the system and the actors in chronological order. Figure 2.2 shows the sequence diagram for the use case `Simulate surgery on an obstructed heart'.

Figure 2.2: Sequence diagram for the use case "Simulate surgery on an obstructed heart"

2.1.3 Fundamental design

The different stages of our application's development are:

· Project analysis: Understanding the needs, defining learning objectives, features, and target users.

· 3D object modeling: Creating digital models of organs, coronary vessels, medical tools, and the surgical environment.

· Model animation: Adding realistic movements (catheter insertion, heartbeat, blood flow) to simulate medical procedures.

· Immersive environment assembly: Integrating the models into a fully interactive and realistic VR scene.

·

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User Interface development: Designing menus, controls, and feedback systems to guide the user through the simulation.

· Visual identity design: Creating the logo, selecting colors and fonts to ensure a consistent visual branding.

· Demo testing: Conducting initial testing to evaluate usability, flow, and relevance of the content.

· Project compilation and testing: Final technical adjustments, debugging, and optimization for deployment.

· Performance tracking integration: Adding a system to monitor user progress, scores, and provide feedback for learning.

2.2 Technical choices

Several technical resources were mobilised to develop the virtual reality simulation application. These can be divided into two main categories: on the one hand, tools dedicated to designing the 3D universe, such as modelling and texturing software; on the other hand, those essential to the functioning of the simulation, including a game engine, a programming language and an SDK adapted to virtual reality.

2.2.1 Choice of 3D modelling and animation software Blender

Blender is a free and open-source software for 3D modeling, animation, rendering, compositing, and video editing. Highly versatile and powerful, it is widely used across fields such as visual effects, game development, architecture, and virtual reality. It enables the creation of realistic or stylized 3D scenes, texturing, lighting, object and character animation, as well as simulation of physical phenomena like smoke, fluids, and collisions. As a cost-free solution, it stands as a strong alternative to expensive professional software. [40]

Originally developed by the Dutch animation studio NeoGeo in the 1990s, Blender was released to the public in 1998. After the bankruptcy of NaN (Not a Number), the company that distributed Blender, the open-source community rallied to buy back the software and continue its development under a free license. Since then, Blender has been actively maintained by the Blender Foundation and a large global community of developers and artists. Today, it is recognized as a professional-grade tool used by both indie creators and major studios. [41]

In our surgical simulation application, Blender was used to create realistic 3D models of the human heart and simulate surgical interactions for treating coronary obstructions. Its sculpting, rigging, and animation tools allowed precise modeling, procedure animation, and immersive visual integration. While alternatives like Autodesk Maya, 3ds Max, Cinema 4D, and ZBrush exist, Blender was chosen for its free access, active community, frequent updates, and seamless compatibility with Unity, making it ideal for efficiently producing realistic biomedical models.

Chapter 2. Conception and technical choices 2.2. Technical choices

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Figure 2.3: Operating room design in Blender 2.2.2 Choice of game engine and programming language

Unity & C-Sharp (C#)

Unity, developed by Unity Technologies, is a widely used cross-platform engine for creating interactive 2D and 3D applications, including VR and AR simulations. Its robust tools for rendering, physics, scripting, and asset management, along with multi-platform deployment, made it ideal for our project. We used Unity 2020.3.41f1 (LTS) for stability and long-term support, leveraging C#, Unity's native language, which offers clean object-oriented syntax, automatic memory management, and seamless integration with Unity's API. This enabled us to efficiently implement VR interactions, simulate surgical procedures, design user interfaces, and maintain a structured, maintainable code-base. The engine also allowed seamless integration with 3D assets created in Blender and facilitated real-time testing of surgical scenarios. Compared to alternatives like Unreal Engine (C++) and Godot (GDScript), Unity provided the best combination of flexibility, performance, and mature VR support, ensuring a smooth development process for our immersive cardiology training software.

Figure 2.4: Using the Unity3D engine to create the VR experience

Chapter 2. Conception and technical choices 2.2. Technical choices

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2.2.3 IDE

To write, debug, and manage our C# scripts within Unity, we used Visual Studio Community 2017. This free, full-featured IDE developed by Microsoft is officially supported by Unity and offers excellent integration with it, including IntelliSense, debugging tools, error tracking, and project organization. Its lightweight setup and reliable performance made it an ideal choice for our workflow, especially in the context of Unity 2020.3.41f1.

Other alternatives like JetBrains Rider, Visual Studio Code, or MonoDevelop exist, but Visual Studio Community stands out due to its deep Unity support, professional-grade features, and longstanding stability. Its compatibility with Unity packages and ease of configuration for VR scripting made it especially valuable during our project.

Figure 2.5: Script for animating the user's hands written in Visual Studio 2017 2.2.4 Choice of SDK and frameworks for YR

· SDK

The Software Development Kit we used is Oculus XR Plugin[43], a comprehensive set of tools, libraries, and resources provided by Unity for developers who want to create virtual reality (VR) experiences for Oculus headsets, including Quest, Quest 2, Quest 3, and Rift devices. It offers robust support for device tracking, controller input, hand tracking, haptic feedback, and platform-specific optimizations, making it easier to build immersive and responsive VR environments. Although primarily designed for Oculus hardware, it can be combined with Unity's XR framework to support cross-platform VR development. The choice of the Oculus XR Plugin in our project is due to its native compatibility with Oculus devices, ensuring precise interactions and smooth locomotion. It also excels in delivering an intuitive and immersive user experience, which was essential for our VR application.

· Frameworks

We used the Unity XR Interaction Toolkit, a flexible framework designed to simplify the creation of VR and AR experiences by providing ready-to-use components for interactions, locomotion, and user interface control [42]. It allows developers to define interactive objects (which users can grab, tap, or manipulate) and interactors, which represent input devices such as VR

Chapter 2. Conception and technical choices 2.3. Development methodology

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controllers or hand tracking. In the context of our project, this toolkit proved essential for enabling intuitive manipulation of surgical tools.

2.2.5 Others softwares Adobe Illustrator

Adobe Illustrator is a widely recognized vector graphics creation software in professional environments. Part of the Adobe suite, it can be used independently or in conjunction with Photoshop, offering powerful vector drawing tools. Vector images, composed of curves defined by mathematical formulas, have the advantage of being resolution-independent, meaning they retain their quality even when enlarged. Illustrator is suitable for creating printed documents as well as illustrations for the web, such as logos and posters. It offers numerous features designed to enhance productivity. For creating the logo of our application, we chose to use Adobe Illustrator CC 2020. Figure 2.6 shows the software interface during its use for designing the logo.

Figure 2.6: Adobe Illustrator interface screenshot

Adobe Photoshop

Adobe Photoshop is a computer-assisted editing, processing, and drawing software, introduced in 1990 and available for MacOS and Windows since 1992. Developed by Adobe, it is primarily used for digital photo processing and also allows for creating images from scratch. Photoshop mainly works with raster images, which are composed of a grid of points called pixels. The advantage of these images is their ability to reproduce subtle color gradations.

2.3 Development methodology

The software was developed using an Iterative and Incremental Development approach, enabling gradual building, testing, and refinement. This methodology is especially suitable for projects involving 3D modeling, VR integration, and interactive software. The main stages of development are

Chapter 2. Conception and technical choices 2.3. Development methodology

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outlined below:

· Specification definition: The project started by defining application requirements and objectives, detailing expected features, user interactions, and the scope of simulated surgical procedures. This stage provided a solid foundation for all subsequent development activities.

· Project planning and task breakdown: The project was divided into smaller, manageable tasks, each producing deliverables that contributed to the overall application. This approach enabled effective progress tracking, task prioritization, and iterative improvements.

· Information gathering: Medical accuracy was ensured by collecting information from online sources, cardiology students, and professional cardiologists. This research informed the VR representation of operating procedures and surgical workflows.

· Scenario and workflow development: Application scenarios and surgical procedure scripts were created to define user interactions, procedural sequences, and expected behaviors within the virtual environment.

· Modeling and asset creation

- Installation and setup of Blender and Adobe Photoshop - Modeling, texturing, and basic animation of 3D objects - Exporting 3D models for integration into Unity

· Integration and Incremental Development in Unity

- Design of the logo and graphic charter to ensure visual consistency;

- User interface (UI) design and layout;

- Installation of Unity and required SDKs;

- Importation of characters and 3D models;

- Creation of different scenes and VR camera configuration;

- Learning and applying C# to implement interactive features;

- Writing scripts to manage events and functionalities;

- Development of incremental features and functionalities;

- Deployment on the Oculus Quest 3 headset for iterative testing;

· Testing, validation, and refinement: Each increment of the application was tested to ensure correct functionality, usability, and immersion. Feedback from testing guided adjustments and improvements, allowing the application to evolve gradually toward the final version.

Conclusion

This chapter has been devoted to presenting the proposed solution, detailing both its design and all the tools used to implement it. We have also described the various stages of the development process, providing an overview of the approach taken to bring the application to fruition. The next chapter will be dedicated to illustrating this solution by presenting some of the application's key interfaces.

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Chapter3

Presentation of the solution and discussions

Introduction

After our solution was implemented, several tests were carried out to verify that it met the client's needs and complied with the planned non-functional requirements. This chapter presents some interfaces captured during the tests carried out on the solution, and a discussion of the shortcomings of the present work.

3.1 Presentation of the software

3.1.1 Visual Identity 3.1.1.1 Main logo design

The CardioTrain logo illustrates the alliance between medicine and innovation. The virtual reality headset symbolises immersive learning, while the electrocardiogram curve joins a heart, evoking life and cardiology. Understated and modern, it reflects the ambition to train differently in order to provide better care.

Figure 3.1: CardioTrain Logo

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3.1.1.2 Color palette and visual harmony

The color palette that we have created for CardioTrain reflects the dual essence of healthcare and technology. It contains:

· The dominant teal shades (#27828C, #278793, #3F9C94) which are the main colours and evoke calm, confidence and scientific precision, essential values in the medical field.

· The brighter blue (#048ABF) that introduces a sense of innovation and vitality, symbolizing the energy of learning and progress.

· The light gray (#F2F2F2) that ensures visual balance and clarity, providing a neutral background that enhances readability and highlights the main elements.

Together, these colors create a serene yet dynamic atmosphere that mirrors the mission of CardioTrain : offering an immersive, safe, and forward-thinking learning experience in cardiology.

Figure 3.2: CardioTrain Color Palette

3.1.1.3 Logo variations and adaptations

To ensure flexibility and visual consistency across all communication materials, the CardioTrain logo was designed in multiple versions adapted to various backgrounds.

The primary version, featuring the teal gradient, embodies the full identity of the brand and is mainly used for digital and presentation purposes.

The monochrome versions, in black and white, ensure readability and contrast when color reproduction is limited or when simplicity is preferred, such as on official documents or technical assets.

Finally, the inverted version allows seamless integration on dark or photographic backgrounds while maintaining the logo's clarity and impact.

These variations guarantee that the CardioTrain identity remains recognizable and professional across all contexts from digital media to print and immersive environments.

Chapter 3. Presentation of the solution and discussions 3.1. Presentation of the software

Figure 3.3: CardioTrain logo variations 3.1.1.4 Logo usage guidelines and restrictions

To preserve the integrity and visual coherence of the CardioTrain identity, the following rules must be strictly observed. It is strictly prohibited to:

· Modify the logo colors or apply non-approved color variations.

· Rotate, tilt, flip, distort, stretch, compress, or alter the logo's proportions or original orientation in any way.

· Add special effects such as shadows, glow, gradients, or textures.

· Place the logo on a busy or overly contrasted background that compromises its readability.

· Add any unapproved elements to the logo (extra text, icons, or slogans).

· Use unofficial, recreated, or outdated versions of the logo.

· Display the logo below the minimum readable size (recommended minimum width: 5cm / 189 px).

These restrictions ensure that the CardioTrain logo remains consistent, professional, and immediately recognizable across all applications.

3.1.1.5 Visual applications

Figure 3.4: A few examples of the logo in use

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Chapter 3. Presentation of the solution and discussions 3.1. Presentation of the software

3.1.2 Software interfaces

· Choice of experience

When the software starts up, a splash screen is shown before the home interface where the user must choose the experience they wish to perform. At this stage, the user can choose between viewing 3D models (healthy heart, obstructed heart or operating room) and performing one of the surgical procedures in assisted or autonomous mode.

Figure 3.5: Home interface

· Selecting and choosing an instrument

The user sees all the instruments laid out on a medical trolley. When the user hovers over each instrument with the joystick pointer, the corresponding name is displayed, allowing it to be clearly identified. Once the desired instrument has been identified, the user can select it using the joystick to use it in the experiment.

Figure 3.6: Selecting and choosing an instrument

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· Chapter 3. Presentation of the solution and discussions 3.1. Presentation of the software

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Assisted experience flow VS Autonomous experience flow

- Assisted mode: The software provides step-by-step instructions that guide the user throughout the simulation. Each task is presented in a specific order to ensure proper understanding and execution. This mode is ideal for beginners or users who prefer a structured approach.

Figure 3.7: Assisted CABG

- Autonomous mode: The user explores and completes the simulation freely, without guided instructions. This mode encourages self-paced learning and allows for more independent practice, ideal for reinforcing previously acquired knowledge.

· 3D models and room exploration

Users can move freely around the virtual room and interact with detailed 3D anatomical models. When they hover over an element, text descriptions appear to provide additional information. They can also observe a healthy heart and a blocked heart to better understand the anatomical differences and medical implications.

Figure 3.8: some 3D operating room exploration screenshots

Chapter 3. Presentation of the solution and discussions 3.2. Challenges encountered and solutions

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Figure 3.9: some 3D hearts exploration screenshots

3.2 Challenges encountered and solutions

During the development of the project, we faced several challenges both at the technical and design levels.

The 3D modeling phase raised particular difficulties, especially with highly complex medical equipment such as the heart-lung machine and the anesthesia machine. Due to their intricate structures, these models were downloaded from Sketchfab instead of being modeled from blender. In addition, 3D models significantly affected both application performance and the overall build size, making the application heavier than expected. In order to address this, we optimized the models by reducing polygon counts, simplifying textures, and selectively replacing certain components with lighter assets, which allowed us to preserve realism while maintaining smooth execution.

Another issue arose when importing models and animations from Blender to Unity. In several cases, the process resulted in visual glitches, unexpected physical collisions, or partial loss of animations. These problems were progressively fixed by carefully reviewing the import settings and testing different export formats until the most stable configuration was identified.

At one stage, certain objects started moving unexpectedly within the scene. After investigation, it was discovered that this was caused by the simultaneous presence of both mesh colliders and box colliders on the same objects. Restarting the debugging process from the beginning allowed us to isolate the problem and resolve it by cleaning up redundant colliders.

We also faced challenges with the choice of SDK, as it directly influenced the Unity version required for proper compatibility. This constraint sometimes limited the features we could use and adapting to it required additional testing and adjustments.

Finally, simulating transitions between physiological states proved to be a significant challenge. Modeling the shift from pathological to normal condition, such as restoring coronary blood flow after an intervention required more than static changes. To ensure immersion, we tried to synchronize animations, shaders, and physiological parameters, allowing for smooth and medically plausible transitions.

However, by combining online researches, trial-and-error experimentation, and the insightful guidance of our supervisor, we were able to identify the right resources and effectively overcome these obstacles.These experiences not only strengthened our technical skills, but also emphasized the importance of patience, iteration, and systematic debugging in XR development.

Chapter 3. Presentation of the solution and discussions 3.3. Discussion

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3.3 Discussion

The developed prototype provides two complementary learning modes: a guided experience and an autonomous experience of PCI and CABG procedures, both designed to address coronary obstructions. Through this application, learners are immersed in a simulated operating room equipped with the necessary instruments, enabling them to become familiar with operative techniques, understand the role of each tool, and progressively develop surgical reflexes in a risk-free, immersive setting. This approach enhances experiential learning and bridges the gap between theoretical knowledge and practice.

Nevertheless, the current version of the prototype presents several limitations. First, the graphical quality, while functional, lacks the photorealism of advanced commercial platforms which integrate highly detailed anatomical models and lighting effects. Second, the system does not yet include complex autonomous scenarios with unexpected complications, which are essential for preparing students for the unpredictability of real-world interventions. Third, the absence of haptic feedback reduces the ability to practice fine motor skills and the tactile dimension of surgery. Fourth, the software is limited to single-user mode and does not support collaborative training sessions, whereas some commercial systems already integrate multi-user experiences.Fifth, the current version does not include detailed assessment tools such as performance metrics, error tracking, or progression analysis, while commercial solutions often provide comprehensive dashboards that enable trainers to objectively evaluate and track learners' skills. Finally, optimization issues such as build size, performance drop with complex assets, and limited device compatibility still restrict large-scale deployment.

Despite these limitations, the proposed solution demonstrates notable strengths. Its accessible cost makes it considerably more affordable than many commercial VR simulators, which often require expensive licenses and specialized hardware. Moreover, its current ability to operate offline ensures that learners can benefit from the training experience without relying on constant internet connectivity.Although it has not yet achieved the sophistication of international benchmarks, it provides a promising, adaptable, and scalable foundation to advance cardiology training through im-mersive technologies.

Conclusion

This chapter demonstrates that the prototype provides an immersive, interactive environment for cardiology training, enabling learners to develop surgical reflexes through guided and autonomous experiences. The development process exposed technical and design challenges, from complex 3D models to smooth physiological transitions, strengthening our optimization and iterative refinement skills. Although limitations remain compared to advanced commercial systems such as absence of haptic feedback, assessment tools and complex scenarios, the prototype's accessible cost, offline functionality, and user-friendly design make it a promising, adaptable, and scalable foundation for cardiology education. Overall, the chapter shows that the solution represents a meaningful step toward bridging the gap between theoretical knowledge and practical skills in immersive medical training.

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General conclusion and perspectives

This work is part of a dynamic of pedagogical innovation through the use of virtual reality. We have designed and developed an immersive application prototype that simulates two major surgical procedures used in the treatment of coronary obstructions: Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI). This solution aims to offer learners a safe, interactive, and autonomous environment to become familiar with surgical techniques, instruments, and the overall process of these procedures.

One of the main strengths of our application is its ability to combine guided assistance with autonomous learning, serving as a complementary tool to support the practical preparation of cardiology students in conjunction with existing training methods. It is expected to provide added value to surgical education, as suggested by studies and tests conducted in several countries [46, 47], by allowing learners to explore, practice, and reinforce their knowledge in a safe, risk-free environment.

The design process we adopted was based on a rigorous analysis of user needs, followed by a technical implementation using tools such as Blender for 3D modeling, Unity for interactive development, and a suitable SDK for VR integration.

Although this first version can still be improved particularly in terms of graphical realism and scenario diversity,it opens the door to promising developments. Future developments will aim to enhance graphical realism, incorporate complex autonomous scenarios with unexpected complications, integrate haptic feedback to support fine motor skills, enable collaborative multi-user experiences, and implement detailed assessment tools such as performance metrics and error tracking. Optimization challenges, including build size, performance with complex assets, and broader device compatibility, will also be addressed. By tackling these limitations, the application can become a more immersive, educationally effective, and widely deployable tool, supporting the ongoing digital transformation of cardiology training while complementing existing teaching methods.

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39

Contents

Dedication ii

Acknowledgements iii

Résumé iv

Abstract iv

iv

v

List of Figures vi

List of Tables vii

List of Acronyms viii

Glossary ix

Introduction 2

1 State of Art 4

Introduction 4

1.1 Coronary artery diseases 4

1.1.1 Overview 4

1.1.2 Coronary artery disease's treatments 5

1.2 Cardiology training issues 8

1.2.1 Current methods of training cardiology students with contextual focus on Benin

8

1.2.2 Limitations of the theoretical approach alone 8

1.2.3 Complication and error rates in initial coronary surgery experiences 9

1.2.4 Existing digital solutions (Excluding immersive technologies) 9

1.3 Immersive technologies in the medical field 11

1.3.1 Virtual Reality as a key immersive technology in medical training 11

1.3.1.1 Types of Virtual Reality experiences in medical education 12

1.3.1.2 Tools and equipment in VR training 12

1.3.1.3 Modalities of use in medical education 12

1.3.2 Pedagogical benefits and cognitive impacts of immersive technologies 13

1.4 VR applications in cardiology 13

1.4.1 Existing projects and tools in cardiology training 13

40

1.4.2 Comparative analysis of existing solutions and benefits of our solution. . . . 16

Conclusion 16

2 Conception and technical choices 18

Introduction 18

2.1 Analysis and design 18

2.1.1 Needs analysis 18

2.1.2 Design 19

2.1.2.1 Technical design 19

2.1.3 Fundamental design 20

2.2 Technical choices 21

2.2.1 Choice of 3D modelling and animation software 21

2.2.2 Choice of game engine and programming language 22

2.2.3 IDE 23

2.2.4 Choice of SDK and frameworks for VR 23

2.2.5 Others softwares 24

2.3 Development methodology 24

Conclusion 25

3 Presentation of the solution and discussions 26

Introduction 26

3.1 Presentation of the software 26

3.1.1 Visual Identity 26

3.1.1.1 Main logo design 26

3.1.1.2 Color palette and visual harmony 27

3.1.1.3 Logo variations and adaptations 27

3.1.1.4 Logo usage guidelines and restrictions 28

3.1.1.5 Visual applications 28

3.1.2 Software interfaces 29

3.2 Challenges encountered and solutions 31

3.3 Discussion 32

Conclusion 32

Conclusion 33

Bibliography 34

Webography 35

Contents 39

41