Hands-on surgical training of congenital heart surgery using 3-dimensional print models

Augmented Reality Visualization of 3D Rotational Angiography in Congenital Heart Disease: A Comparative Study to Standard Computer Visualization

Augmented reality (AR) visualization of 3D rotational angiography (3DRA) provides 3D representations of cardiac structures with full visualization of the procedural environment. The purpose of this study was to evaluate the feasibility of converting 3DRAs of congenital heart disease patients to AR models, highlight the workflow for 3DRA optimization for AR visualization, and assess physicians' perceptions of their use. This single-center study prospectively evaluated 30 retrospectively-acquired 3DRAs that were converted to AR, compared to Computer Models (CM). Median patient age 6.5 years (0.24-38.8) and weight 20.6 kg (3.4-107.0). AR and CM quality were graded highly. RV pacing was associated with higher quality of both model types (p = 0.02). Visualization and identification of structures were graded as "very easy" in 81.1% (n = 73) and 67.8% (n = 61) of AR and CM, respectively. Fifty-nine (66%) grades 'Agreed' or 'Strongly Agreed' that AR models provided superior appreciation of 3D relationships; AR was found to be least beneficial in visualization of aortic arch obstruction. AR models were thought to be helpful in identifying pathology and assisting in interventional planning in 85 assessments (94.4%). There was significant potential seen in the opportunity for patient/family counseling and trainee/staff education with AR models. It is feasible to convert 3D models of 3DRAs into AR models, which are of similar image quality as compared to CM. AR models provided additional benefits to visualization of 3D relationships in most anatomies. Future directions include integration of interventional simulation, peri-procedural counseling of patients and families, and education of trainees and staff with AR models.

Training the Next Generation of Transplant Surgeons With a 3-Dimensional Trainer: A Pilot Study

Background

In the United States, no published guidelines promote exposure to technical variants (ie, living donor or split liver) during transplant fellowship. Simulation with hands-on liver models may improve training in transplantation. This pilot study addressed 3 overall goals (material and model creation tools, recruitment rates and assessment of workload, and protocol adherence).

Methods

A patient-specific hands-on liver model was constructed from clinical imaging, and it needed to be resilient and realistic. Multiple types of materials were tested between January 2020 and August 2022. Participants were recruited stepwise. A left lateral segmentectomy simulation was conducted between August 2022 and December 2022 to assess protocol adherence.

Results

Digital anatomy 3-dimensional printing was considered the best option for the hands-on liver model. The recruitment rate was 100% and 47% for junior attendings and surgical residents, respectively. Ten participants were included and completed all the required surveys. Seven (70%) and 6 (60%) participants "agreed" that the overall quality of the model and the material were acceptable for surgical simulation. Five participants (50%) "agreed" that the training improved their surgical skills. Nine participants (90%) "strongly agreed" that similar sessions should be included in surgical training programs.

Conclusions

Three-dimensional hands-on liver models have the advantage of tactile feedback and were rated favorably as a potential training tool. Study enrollment for further studies is possible with the support of leadership. Rigorous multicenter designs should be developed to measure the actual impact of 3-dimensional hands-on liver models on surgical training.

Post-printing processing and aging effects on Polyjet materials intended for the fabrication of advanced surgical simulators

Material Jetting (MJ) 3D printing technology is promising for the fabrication of highly realistic surgical simulators, however, the changes in the mechanical properties of MJ materials after post-printing treatments and over time remain quite unknown. In this study, we investigate the effect of different post-printing processes and aging on the mechanical properties of a white opaque and rigid MJ photopolymer, a white flexible MJ photopolymer and on a combination of them. Tensile and Shore hardness tests were conducted on homogeneous 3D-printed specimens: two different post-printing procedures for support removal (dry and water) and further surface treatment (with glycerol solution) were compared. The specimens were tested within 48 h from printing and after aging (30-180 days) in a controlled environment. All groups of specimens treated with different post-printing processes (dry, water, glycerol) exhibited a statistically significant difference in mechanical properties (i.e. elongation at break, elastic modulus, ultimate tensile strength). Particularly, the treatment with glycerol makes the flexible photopolymer more rigid, but then with aging the initial elongation of the material tends to be restored. For the rigid photopolymer, an increase in deformability was observed as a major effect of aging. The hardness tests on the printed specimens highlighted a significant overestimation of the Shore values declared by the manufacturer. The study findings are useful for guiding the material selection and post-printing processing techniques to manufacture realistic and durable models for surgical training.

Teaching hypospadias repair by utilising a novel 3D-printed silicon model: An initial assessment using structured trainee and trainer feedback

INTRODUCTION

Simulated paediatric surgical training is inherently advantageous and flourishing. Moreover, several working conditions resulted in reduced training hours, index and subspecialty cases encountered, and the COVID-19 pandemic affected elective surgery backlogs, hence training opportunities. Hypospadias repair is technically-demanding and requires a spectrum of dissective and reconstructive skills. We therefore aimed to test a 3D-printed silicon model for hypospadias repair, in the context of hands-on surgical training.

MATERIAL AND METHODS

Twenty-Seven trainees, under the supervision of 15 instructors, completed the activity. They were given a seminar to show the relevant anatomy, and 8 key steps of the exercise: (1)-degloving; (2)-urethral plate marking; (3)-incision; (4)-tubularisation; (5)-glansplasty/glanuloplasty; (6)-dartos layer preparation; (7)-preputioplasty and (8)-skin closure. Each trainee completed a structured feedback assessment. An on-site trainer supervised and evaluated each exercise. Trainees and trainers rated the model through the above steps from unsatisfactory-(1/5) to excellent-(5/5), presented herein via cross-sectional analysis.

RESULTS

Eleven-(40.7 %) trainees were in years:1-3 of specialist training, 10-(37 %) were in years:4-6, and 6-(22.2 %) were beyond year-6. Two-(7.4 %) trainees had nil-hypospadias experience, 16-(59.2 %) previously assisted in procedures or performed steps, 5-(18.5 %) performed whole procedures supervised and 4-(14.8 %) independently. Twenty-(74 %) trainees and 15-(100 %) instructors judged the model to resemble the anomaly. Seventeen-(63 %) trainees and 13-(86.6 %) instructors rated the material needle-penetrability ≥3/5, compared to human tissue. Sixteen-(59 %) trainees and 13-(86.6 %) instructors rated the material suture holding ≥3/5. Eleven-(73.3 %) trainees and 13-(86.6 %) instructors rated sutures' evenness and edge coaptability ≥3/5.

DISCUSSION

Hypospadias is an index operation, which requires precision skills. Simulated training in Paediatric Surgery and Urology is gaining importance. 3D-printed models are gaining a key role in simulated training. The study presents a novel 3D-printed high-fidelity silicon-based hypospadias model designed for hands-on training. A structured pathway to divide a standard hypospadias repair into key steps is displayed to ensure skill acquisition and stabilisation.

CONCLUSION

This 3D-printed silicon-based hypospadias model is proven useful for hands-on training. The fidelity can still improve, especially regarding suture holding of the material.

LEVEL OF EVIDENCE

LEVEL III.

The effect of 3D modeling on family quality of life, surgical success, and patient outcomes in congenital heart diseases: objectives and design of a randomized controlled trial

BACKGROUND

Understanding the severity of the disease from the parents' perspective can lead to better patient outcomes, improving both the child's health-related quality of life and the family's quality of life. The implementation of 3-dimensional (3D) modeling technology in care is critical from a translational science perspective.

AIM

The purpose of this study is to determine the effect of 3D modeling on family quality of life, surgical success, and patient outcomes in congenital heart diseases. Additionally, we aim to identify challenges and potential solutions related to this innovative technology.

METHODS

The study is a two-group pretest-posttest randomized controlled trial protocol. The sample size is 15 in the experimental group and 15 in the control group. The experimental group's heart models will be made from their own computed tomography (CT) images and printed using a 3D printer. The experimental group will receive surgical simulation and preoperative parent education with their 3D heart model. The control group will receive the same parent education using the standard anatomical model. Both groups will complete the Sociodemographic Information Form, the Surgical Simulation Evaluation Form - Part I-II, and the Pediatric Quality of Life Inventory (PedsQL) Family Impacts Module. The primary outcome of the research is the average PedsQL Family Impacts Module score. Secondary outcome measurement includes surgical success and patient outcomes. Separate analyses will be conducted for each outcome and compared between the intervention and control groups.

CONCLUSIONS

Anomalies that can be clearly understood by parents according to the actual size and dimensions of the child's heart will affect the preoperative preparation of the surgical procedure and the recovery rate in the postoperative period.

Design and Analysis of a Polymeric Left Ventricular Simulator via Computational Modelling

Preclinical testing of medical devices is an essential step in the product life cycle, whereas testing of cardiovascular implants requires specialised testbeds or numerical simulations using computer software Ansys 2016. Existing test setups used to evaluate physiological scenarios and test cardiac implants such as mock circulatory systems or isolated beating heart platforms are driven by sophisticated hardware which comes at a high cost or raises ethical concerns. On the other hand, computational methods used to simulate blood flow in the cardiovascular system may be simplified or computationally expensive. Therefore, there is a need for low-cost, relatively simple and efficient test beds that can provide realistic conditions to simulate physiological scenarios and evaluate cardiovascular devices. In this study, the concept design of a novel left ventricular simulator made of latex rubber and actuated by pneumatic artificial muscles is presented. The designed left ventricular simulator is geometrically similar to a native left ventricle, whereas the basal diameter and long axis length are within an anatomical range. Finite element simulations evaluating left ventricular twisting and shortening predicted that the designed left ventricular simulator rotates approximately 17 degrees at the apex and the long axis shortens around 11 mm. Experimental results showed that the twist angle is 18 degrees and the left ventricular simulator shortens 5 mm. Twist angles and long axis shortening as in a native left ventricle show it is capable of functioning like a native left ventricle and simulating a variety of scenarios, and therefore has the potential to be used as a test platform.

Application of three-dimensional printing in cardiovascular diseases: a bibliometric analysis

AIM

This paper aimed to explore the application of three-dimensional (3D) printing in cardiovascular diseases, to reach an insight in this field and prospect the future trend.

METHODS

The articles were selected from the Web of Science Core Collection database. Excel 2019, VOSviewer 1.6.16, and CiteSpace 6.1.R6 were used to analyze the information.

RESULTS

A total of 467 papers of 3D printing in cardiovascular diseases were identified, and the first included literature appeared in 2000. A total of 692 institutions from 52 countries participated in the relevant research, while the United States of America contributed to 160 articles and were in a leading position. The most productive institution was Curtin University , and Zhonghua Sun who has posted the most articles ( n =8) was also from there. The Frontiers in Cardiovascular Medicine published most papers ( n =25). The Journal of Thoracic and Cardiovascular Surgery coveted the most citations ( n =520). Related topics of frontiers will still focus on congenital heart disease, valvular heart disease, and left atrial appendage closure.

CONCLUSIONS

The authors summarized the publication information of the application of 3D printing in cardiovascular diseases related literature from 2000 to 2023, including country and institution of origin, authors, and publication journal. This study can reflect the current hotspots and novel directions for the application of 3D printing in cardiovascular diseases.

The introduction of surgical simulation on three-dimensional-printed models in the cardiac surgery curriculum: an experimental project

AIMS

Training in congenital cardiac surgery has become more and more difficult because of the reduced opportunities for trainees in the operating room and the high patient anatomical variability. The aim of this study was to perform a pilot evaluation of surgical simulation on a simple 3D-printed heart model in training of young surgeons and its potential inclusion in the curriculum of residency programs.

METHODS

A group of 11 residents performed a surgical correction of aortic coarctation using a 3D-printed surgical model. After teaching the surgical procedure, a simulation was performed twice, at different times, and was evaluated quantitatively and qualitatively by a senior surgeon. A 3D model-based training program was then developed and incorporated into our cardiac surgery training program.

RESULTS

A significant improvement in surgical technique was observed between the first and second surgical simulations: median of 65% [interquartile range (IQR) = 61-70%] vs. 83% (IQR = 82-91%, P < 0.001). The median time required to run the simulation was significantly shorter during the second simulation: 39 min (IQR = 33-40) vs. 45 min (IQR = 37-48; P = 0.02). Regarding the simulation program, a basic and an advanced program were developed, including a total of 40 different simulated procedures divided into 12 sessions.

CONCLUSION

Surgical simulation using 3D-printing technology can be an extremely valuable tool to improve surgical training in congenital heart disease. Our pilot study can represent the first step towards the creation of an integrated training system on 3D-printed models of congenital and acquired heart diseases in other Italian residency programs.

Advanced imaging and modeling in neonatal simulation

Advances in modeling and imaging have resulted in realistic tools that can be applied to education and training, and even direct patient care. These include point-of-care ultrasound (POCUS), 3-dimensional and digital anatomic modeling, and extended reality. These technologies have been used for the preparation of complex patient care through simulation-based clinical rehearsals, direct patient care such as the creation of patient devices and implants, and for simulation-based education and training for health professionals, patients and families. In this section, we discuss these emerging technologies and describe how they can be utilized to improve patient care.

A Systematic Analysis of Additive Manufacturing Techniques in the Bioengineering of In Vitro Cardiovascular Models

Additive Manufacturing is noted for ease of product customization and short production run cost-effectiveness. As our global population approaches 8 billion, additive manufacturing has a future in maintaining and improving average human life expectancy for the same reasons that it has advantaged general manufacturing. In recent years, additive manufacturing has been applied to tissue engineering, regenerative medicine, and drug delivery. Additive Manufacturing combined with tissue engineering and biocompatibility studies offers future opportunities for various complex cardiovascular implants and surgeries. This paper is a comprehensive overview of current technological advancements in additive manufacturing with potential for cardiovascular application. The current limitations and prospects of the technology for cardiovascular applications are explored and evaluated.

E-Health: A Game Changer in Fetal and Neonatal Cardiology?

Technological advancements have greatly impacted the healthcare industry, including the integration of e-health in pediatric cardiology. The use of telemedicine, mobile health applications, and electronic health records have demonstrated a significant potential to improve patient outcomes, reduce healthcare costs, and enhance the quality of care. Telemedicine provides a useful tool for remote clinics, follow-up visits, and monitoring for infants with congenital heart disease, while mobile health applications enhance patient and parents' education, medication compliance, and in some instances, remote monitoring of vital signs. Despite the benefits of e-health, there are potential limitations and challenges, such as issues related to availability, cost-effectiveness, data privacy and security, and the potential ethical, legal, and social implications of e-health interventions. In this review, we aim to highlight the current application and perspectives of e-health in the field of fetal and neonatal cardiology, including expert parents' opinions.

Three-Dimensional Bioprinting in Cardiovascular Disease: Current Status and Future Directions

Three-dimensional (3D) printing plays an important role in cardiovascular disease through the use of personalised models that replicate the normal anatomy and its pathology with high accuracy and reliability. While 3D printed heart and vascular models have been shown to improve medical education, preoperative planning and simulation of cardiac procedures, as well as to enhance communication with patients, 3D bioprinting represents a potential advancement of 3D printing technology by allowing the printing of cellular or biological components, functional tissues and organs that can be used in a variety of applications in cardiovascular disease. Recent advances in bioprinting technology have shown the ability to support vascularisation of large-scale constructs with enhanced biocompatibility and structural stability, thus creating opportunities to replace damaged tissues or organs. In this review, we provide an overview of the use of 3D bioprinting in cardiovascular disease with a focus on technologies and applications in cardiac tissues, vascular constructs and grafts, heart valves and myocardium. Limitations and future research directions are highlighted.

CMR and Percutaneous Treatment of Pulmonary Regurgitation: Outreach the Search for the Best Candidate

Performance of cardiovascular magnetic resonance (CMR) in the planning phase of percutaneous pulmonary valve implantation (PPVI) is needed for the accurate delineation of the right ventricular outflow tract (RVOT), coronary anatomy and the quantification of right ventricular (RV) volume overload in patients with significant pulmonary regurgitation (PR). This helps to find the correct timings for the intervention and prevention of PPVI-related complications such as coronary artery compression, device embolization and stent fractures. A defined CMR study protocol should be set for all PPVI candidates to reduce acquisition times and acquire essential sequences that are determinants for PPVI success. For correct RVOT sizing, contrast-free whole-heart sequences, preferably at end-systole, should be adopted in the pediatric population thanks to their high reproducibility and concordance with invasive angiographic data. When CMR is not feasible or contraindicated, cardiac computed tomography (CCT) may be performed for high-resolution cardiac imaging and eventually the acquisition of complementary functional data. The aim of this review is to underline the role of CMR and advanced multimodality imaging in the context of pre-procedural planning of PPVI concerning its current and potential future applications.

Annotated computed tomography coronary angiogram images and associated data of normal and diseased arteries

Computed Tomography Coronary Angiography (CTCA) is a non-invasive method to evaluate coronary artery anatomy and disease. CTCA is ideal for geometry reconstruction to create virtual models of coronary arteries. To our knowledge there is no public dataset that includes centrelines and segmentation of the full coronary tree. We provide anonymized CTCA images, voxel-wise annotations and associated data in the form of centrelines, calcification scores and meshes of the coronary lumen in 20 normal and 20 diseased cases. Images were obtained along with patient information with informed, written consent as part of the Coronary Atlas. Cases were classified as normal (zero calcium score with no signs of stenosis) or diseased (confirmed coronary artery disease). Manual voxel-wise segmentations by three experts were combined using majority voting to generate the final annotations. Provided data can be used for a variety of research purposes, such as 3D printing patient-specific models, development and validation of segmentation algorithms, education and training of medical personnel and in-silico analyses such as testing of medical devices.

Training on Congenital 3D Cardiac Models - Will Models Improve Surgical Performance?

Technical skill development in congenital heart surgery (CHS) is challenging due to numerous factors which potentially limit the hands-on operative exposure in surgical training. These challenges have stimulated the growth of simulation-based training through the development of 3D-printed models, providing hands-on surgical training (HOST). From its inception in 2015, the models used in the HOST program have constantly improved, and now include valvar/subvalvar apparatus and better materials that mimic real tissue. Evidence shows that deliberate, regular simulation practice can improve a surgeon's technical skills across the spectrum of CHS. Furthermore, surgical trainees who undergo simulation training are able to translate this improved performance into the operative environment with improved patient outcomes. Despite evidence to support the incorporation of simulation methods into congenital training, its widespread adoption into training curricula remains low. This is due to numerous factors including funding, lack of dedicated time or proctorship and access to models-all of which can be overcome with the newer generation of models and committed trainers. Training programs should consider incorporating simulation-methods as a routine component of congenital training programs.

Advances in pelvic imaging parameters predicting surgical difficulty in rectal cancer

Due to the fixed bony structure of the pelvis, the pelvic operation space is limited, complicating the surgical operation of rectal cancer, especially middle and low rectal cancer. The closer the tumor is to the anal verge, the smaller the operative field and operating space, the longer the operative time, and the greater the incidence of intraoperative side injuries and postoperative complications. To date, there is still no clear definition of a difficult pelvis that affects the surgical operation of rectal cancer. Few related research reports exist in the literature, and views on this aspect are not the same between countries. Therefore, it is particularly important to predict the difficulty of rectal cancer surgery in a certain way before surgery and to select the surgical method most suitable for each case during the treatment of rectal cancer.

Patient-Specific 3D-Printed Low-Cost Models in Medical Education and Clinical Practice

3D printing has been increasingly used for medical applications with studies reporting its value, ranging from medical education to pre-surgical planning and simulation, assisting doctor-patient communication or communication with clinicians, and the development of optimal computed tomography (CT) imaging protocols. This article presents our experience of utilising a 3D-printing facility to print a range of patient-specific low-cost models for medical applications. These models include personalized models in cardiovascular disease (from congenital heart disease to aortic aneurysm, aortic dissection and coronary artery disease) and tumours (lung cancer, pancreatic cancer and biliary disease) based on CT data. Furthermore, we designed and developed novel 3D-printed models, including a 3D-printed breast model for the simulation of breast cancer magnetic resonance imaging (MRI), and calcified coronary plaques for the simulation of extensive calcifications in the coronary arteries. Most of these 3D-printed models were scanned with CT (except for the breast model which was scanned using MRI) for investigation of their educational and clinical value, with promising results achieved. The models were confirmed to be highly accurate in replicating both anatomy and pathology in different body regions with affordable costs. Our experience of producing low-cost and affordable 3D-printed models highlights the feasibility of utilizing 3D-printing technology in medical education and clinical practice.

Patient-Specific 3D-Printed Models in Pediatric Congenital Heart Disease

Three-dimensional (3D) printing technology has become increasingly used in the medical field, with reports demonstrating its superior advantages in both educational and clinical value when compared with standard image visualizations or current diagnostic approaches. Patient-specific or personalized 3D printed models serve as a valuable tool in cardiovascular disease because of the difficulty associated with comprehending cardiovascular anatomy and pathology on 2D flat screens. Additionally, the added value of using 3D-printed models is especially apparent in congenital heart disease (CHD), due to its wide spectrum of anomalies and its complexity. This review provides an overview of 3D-printed models in pediatric CHD, with a focus on educational value for medical students or graduates, clinical applications such as pre-operative planning and simulation of congenital heart surgical procedures, and communication between physicians and patients/parents of patients and between colleagues in the diagnosis and treatment of CHD. Limitations and perspectives on future research directions for the application of 3D printing technology into pediatric cardiology practice are highlighted.

Advanced 3D Visualization and 3D Printing in Radiology

Since the discovery of X-rays in 1895, medical imaging systems have played a crucial role in medicine by permitting the visualization of internal structures and understanding the function of organ systems. Traditional imaging modalities including Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Ultrasound (US) present fixed two-dimensional (2D) images which are difficult to conceptualize complex anatomy. Advanced volumetric medical imaging allows for three-dimensional (3D) image post-processing and image segmentation to be performed, enabling the creation of 3D volume renderings and enhanced visualization of pertinent anatomic structures in 3D. Furthermore, 3D imaging is used to generate 3D printed models and extended reality (augmented reality and virtual reality) models. A 3D image translates medical imaging information into a visual story rendering complex data and abstract ideas into an easily understood and tangible concept. Clinicians use 3D models to comprehend complex anatomical structures and to plan and guide surgical interventions more precisely. This chapter will review the volumetric radiological techniques that are commonly utilized for advanced 3D visualization. It will also provide examples of 3D printing and extended reality technology applications in radiology and describe the positive impact of advanced radiological image visualization on patient care.

Clinical Applications of Mixed Reality and 3D Printing in Congenital Heart Disease

Understanding the anatomical features and generation of realistic three-dimensional (3D) visualization of congenital heart disease (CHD) is always challenging due to the complexity and wide spectrum of CHD. Emerging technologies, including 3D printing and mixed reality (MR), have the potential to overcome these limitations based on 2D and 3D reconstructions of the standard DICOM (Digital Imaging and Communications in Medicine) images. However, very little research has been conducted with regard to the clinical value of these two novel technologies in CHD. This study aims to investigate the usefulness and clinical value of MR and 3D printing in assisting diagnosis, medical education, pre-operative planning, and intraoperative guidance of CHD surgeries through evaluations from a group of cardiac specialists and physicians. Two cardiac computed tomography angiography scans that demonstrate CHD of different complexities (atrial septal defect and double outlet right ventricle) were selected and converted into 3D-printed heart models (3DPHM) and MR models. Thirty-four cardiac specialists and physicians were recruited. The results showed that the MR models were ranked as the best modality amongst the three, and were significantly better than DICOM images in demonstrating complex CHD lesions (mean difference (MD) = 0.76, p = 0.01), in enhancing depth perception (MD = 1.09, p = 0.00), in portraying spatial relationship between cardiac structures (MD = 1.15, p = 0.00), as a learning tool of the pathology (MD = 0.91, p = 0.00), and in facilitating pre-operative planning (MD = 0.87, p = 0.02). The 3DPHM were ranked as the best modality and significantly better than DICOM images in facilitating communication with patients (MD = 0.99, p = 0.00). In conclusion, both MR models and 3DPHM have their own strengths in different aspects, and they are superior to standard DICOM images in the visualization and management of CHD.

Congenital Heart Surgery Skill Training Using Simulation Models: Not an Option but a Necessity

Congenital heart surgery (CHS) is technically demanding, and its training is extremely complex and challenging. Training of the surgeon's technical skills has relied on a preceptorship format in which the trainees are gradually exposed to patients in the operating room under the close tutelage of senior staff surgeons. Training in the operating room is an inefficient process and the concept of a learning curve is no longer acceptable in terms of patient outcomes. The benefits of surgical simulation in training of congenital heart surgeons are well known and appreciated. However, adequate surgical simulation models and equipment for training have been scarce until the recent development of three-dimensionally (3D) printed models. Using comprehensive 3D printing and silicone-molding techniques, realistic simulation training models for most congenital heart surgical procedures have been produced. Newly developed silicone-molded models allow efficient CHS training in a stress-free environment with instantaneous feedback from the proctors and avoids risk to patients. The time has arrived when all congenital heart surgeons should consider surgical simulation training before progressing to real-life operating in a similar fashion to the aviation industry where all pilots are required to complete simulation training before flying a real aircraft. It is argued here that simulation training is not an option anymore but should be a mandatory component of CHS training.

3D Printed Models in Cardiovascular Disease: An Exciting Future to Deliver Personalized Medicine

3D printing has shown great promise in medical applications with increased reports in the literature. Patient-specific 3D printed heart and vascular models replicate normal anatomy and pathology with high accuracy and demonstrate superior advantages over the standard image visualizations for improving understanding of complex cardiovascular structures, providing guidance for surgical planning and simulation of interventional procedures, as well as enhancing doctor-to-patient communication. 3D printed models can also be used to optimize CT scanning protocols for radiation dose reduction. This review article provides an overview of the current status of using 3D printing technology in cardiovascular disease. Limitations and barriers to applying 3D printing in clinical practice are emphasized while future directions are highlighted.

The application of 3D printing in preoperative planning for transcatheter aortic valve replacement: a systematic review

BACKGROUND

Recently, transcatheter aortic valve replacement (TAVR) has been suggested as a less invasive treatment compared to surgical aortic valve replacement, for patients with severe aortic stenosis. Despite the attention, persisting evidence suggests that several procedural complications are more prevalent with the transcatheter approach. Consequently, a systematic review was undertaken to evaluate the application of three-dimensional (3D) printing in preoperative planning for TAVR, as a means of predicting and subsequently, reducing the incidence of adverse events.

METHODS

MEDLINE, Web of Science and Embase were searched to identify studies that utilised patient-specific 3D printed models to predict or mitigate the risk of procedural complications.

RESULTS

13 of 219 papers met the inclusion criteria of this review. The eligible studies have shown that 3D printing has most commonly been used to predict the occurrence and severity of paravalvular regurgitation, with relatively high accuracy. Studies have also explored the usefulness of 3D printed anatomical models in reducing the incidence of coronary artery obstruction, new-onset conduction disturbance and aortic annular rapture.

CONCLUSION

Patient-specific 3D models can be used in pre-procedural planning for challenging cases, to help deliver personalised treatment. However, the application of 3D printing is not recommended for routine clinical practice, due to practicality issues.

Imaging-Based, Patient-Specific Three-Dimensional Printing to Plan, Train, and Guide Cardiovascular Interventions: A Systematic Review and Meta-Analysis

BACKGROUND

To tailor cardiovascular interventions, the use of three-dimensional (3D), patient-specific phantoms (3DPSP) encompasses patient education, training, simulation, procedure planning, and outcome-prediction.

AIM

This systematic review and meta-analysis aims to investigate the current and future perspective of 3D printing for cardiovascular interventions.

METHODS

We systematically screened articles on Medline and EMBASE reporting the prospective use of 3DPSP in cardiovascular interventions by using combined search terms. Studies that compared intervention time depending on 3DPSP utilisation were included into a meta-analysis.

RESULTS

We identified 107 studies that prospectively investigated a total of 814 3DPSP in cardiovascular interventions. Most common settings were congenital heart disease (CHD) (38 articles, 6 comparative studies), left atrial appendage (LAA) occlusion (11 articles, 5 comparative, 1 randomised controlled trial [RCT]), and aortic disease (10 articles). All authors described 3DPSP as helpful in assessing complex anatomic conditions, whereas poor tissue mimicry and the non-consideration of physiological properties were cited as limitations. Compared to controls, meta-analysis of six studies showed a significant reduction of intervention time in LAA occlusion (n=3 studies), and surgery due to CHD (n=3) if 3DPSPs were used (Cohen's d=0.54; 95% confidence interval, 0.13 to 0.95; p=0.001), however heterogeneity across studies should be taken into account.

CONCLUSIONS

3DPSP are helpful to plan, train, and guide interventions in patients with complex cardiovascular anatomy. Benefits for patients include reduced intervention time with the potential for lower radiation exposure and shorter mechanical ventilation times. More evidence and RCTs including clinical endpoints are needed to warrant adoption of 3DPSP into routine clinical practice.

Clinical Translation Of Surgical Simulated Closure Of A Ventricular Septum Defect

OBJECTIVES

To demonstrate that improvement in technical performance of congenital heart surgical trainees during ventricular septal defect(VSD) closure simulation translates to better patient outcomes.

METHODS

Seven trainees were divided into two groups. Experienced-fellows group included four senior trainees who had performed>five VSD closures. Residents group consisted of three residents who had never performed a VSD closure. Experienced-fellows completed 3 VSD closures on real patients as a pretest. Both groups participated in a four-week simulation requiring each participant to complete two VSD closures on 3D-printed models per week. One-month later all trainees returned for a posttest operation in real patients. All performances were recorded, blinded and scored independently by two cardiac surgeons using the validated Hands-On Surgical Training-Congenital Heart Surgery(HOST-CHS). Predefined surgical outcomes were analyzed.

RESULTS

The median HOST-CHS score increased significantly from week one to four [50(39,58) vs.73(65,74), p < 0.001] during simulation. The improvement in the simulation of experienced-fellows successfully transferred to skill acquisition[HOST-CHS score 72.5(71, 74)vs.54(51, 60), p < 0.001], with better patients outcomes including shorter total cross-clamp time[pretest: 86(70,99) vs.posttest: 60(53, 64) min, p = 0.006], and reduced incidence of major patch leak requiring multiple pump runs[pretest: 4/11vs.posttest: 0/9, p = 0.043]. After simulation, the technical performance and surgical outcomes of residents were comparable to experienced-fellows in real patients, except for significantly longer cross-clamp time[Residents : 76.5(71.7,86.8)vs.Experienced-fellows : 60(53,64) min, p = 0.002].

CONCLUSIONS

Deliberate practice using simulation translates to better performance and surgical outcomes in real patients. Residents who had never completed a VSD closure could perform the procedures just as safely and effectively as their senior colleagues following simulation.

Comparison of blood pool and myocardial 3D printing in the diagnosis of types of congenital heart disease

The study aimed to evaluate the effectiveness of blood pool and myocardial models made by stereolithography in the diagnosis of different types of congenital heart disease (CHD). Two modeling methods were applied in the diagnosis of 8 cases, and two control groups consisting of experts and students diagnosed the cases using echocardiography with computed tomography, blood pool models, and myocardial models. The importance, suitability, and simulation degree of different models were analyzed. The average diagnostic rate before and after 3D printing was used was 88.75% and 95.9% (P = 0.001) in the expert group and 60% and 91.6% (P = 0.000) in the student group, respectively. 3D printing was considered to be more important for the diagnosis of complex CHDs (very important; average, 87.8%) than simple CHDs (very important; average, 30.8%) (P = 0.000). Myocardial models were considered most realistic regarding the structure of the heart (average, 92.5%). In cases of congenital corrected transposition of great arteries, Williams syndrome, coronary artery fistula, tetralogy of Fallot, patent ductus arteriosus, and coarctation of the aorta, blood pool models were considered more effective (average, 92.1%), while in cases of double outlet right ventricle and ventricular septal defect, myocardial models were considered optimal (average, 80%).

3D-printed heart models for hands-on training in pediatric cardiology - the future of modern learning and teaching?

BACKGROUND

This project aims to develop a new concept in training pediatric cardiologists to meet the requirements of interventional cardiac catheterizations today in terms of complexity and importance. This newly developed hands-on training program is supposed to enable the acquisition of certain skills which are necessary when investigating and treating patients in a catheter laboratory.

METHODS

Based on anonymous CT-scans of pediatric patients' digital 3D heart models with or without cardiac defects were developed and printed three-dimensionally in a flexible material visible under X-ray. Hands-on training courses were offered using models of a healthy heart and the most common congenital heart defects (CHD). An evaluation was performed by quantifying fluoroscopy times (FL-time) and a questionnaire.

RESULTS

The acceptance of theoretical and practical contents within the hands-on training was very positive. It was demonstrated that it is possible to master various steps of a diagnostic procedure and an intervention as well as to practice and repeat them independently which significantly reduced FL-time. The participants stated that the hands-on training led to more confidence in interventions on real patients.

CONCLUSION

With the development of a training module using 3D-printed heart models, basic and advanced training in the field of diagnostic cardiac examinations as well as interventional therapies of CHD is possible. The learning effect for both, practical skills and theoretical understanding, was significant which underlines the importance of integrating such hands-on trainings on 3D heart models in education and practical training.

Translating Imaging Into 3D Printed Cardiovascular Phantoms

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3D printed patient specific phantoms can visualize complex cardiovascular anatomy

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Common imaging modalities for 3D printing are CCT and CMR

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Material jetting/PolyJet and stereolithography are widely used printing techniques

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Standardized validation is warranted to compare different 3D printing technologies

Translation of imaging into 3-dimensional (3D) printed patient-specific phantoms (3DPSPs) can help visualize complex cardiovascular anatomy and enable tailoring of therapy. The aim of this paper is to review the entire process of phantom production, including imaging, materials, 3D printing technologies, and the validation of 3DPSPs. A systematic review of published research was conducted using Embase and MEDLINE, including studies that investigated 3DPSPs in cardiovascular medicine. Among 2,534 screened papers, 212 fulfilled inclusion criteria and described 3DPSPs as a valuable adjunct for planning and guiding interventions (n = 108 [51%]), simulation of physiological or pathological conditions (n = 19 [9%]), teaching of health care professionals (n = 23 [11%]), patient education (n = 3 [1.4%]), outcome prediction (n = 6 [2.8%]), or other purposes (n = 53 [25%]). The most common imaging modalities to enable 3D printing were cardiac computed tomography (n = 131 [61.8%]) and cardiac magnetic resonance (n = 26 [12.3%]). The printing process was conducted mostly by material jetting (n = 54 [25.5%]) or stereolithography (n = 43 [20.3%]). The 10 largest studies that evaluated the geometric accuracy of 3DPSPs described a mean bias <±1 mm; however, the validation process was very heterogeneous among the studies. Three-dimensional printed patient-specific phantoms are highly accurate, used for teaching, and applied to guide cardiovascular therapy. Systematic comparison of imaging and printing modalities following a standardized validation process is warranted to allow conclusions on the optimal production process of 3DPSPs in the field of cardiovascular medicine.

DEVELOPMENT OF A THREE-DIMENSIONAL-PRINTED HEART MODEL REPLICATING THE ELASTICITY, TEAR RESISTANCE, AND HARDNESS OF PIG HEART USING AGILUS AND TANGO

This study proposes a manufacturing method for reproducing some physical properties of the heart by comparing the elasticity, tear resistance, and hardness of a pig heart and three-dimensional printing materials, Agilus and Tango. A Digital Force Gauge was used to analyze elastic modulus and tear resistance, whereas a Shore A hardness meter was used to measure hardness. Agilus and Tango had 10 and 5 times higher elasticity, respectively, 2 and 4 times higher tear resistance, and a higher Shore A hardness than the pig heart. In summary, the pig heart had a more similar elasticity and Shore A hardness than the Tango sample, whereas more tear resistance was similar to the Agilus sample. Therefore, we proposed elasticity and tear resistance equations that can be used to build a heart model and a conversion table for heart fabrication at various thicknesses.

Soft-Tissue-Mimicking Using Hydrogels for the Development of Phantoms

With the currently available materials and technologies it is difficult to mimic the mechanical properties of soft living tissues. Additionally, another significant problem is the lack of information about the mechanical properties of these tissues. Alternatively, the use of phantoms offers a promising solution to simulate biological bodies. For this reason, to advance in the state-of-the-art a wide range of organs (e.g., liver, heart, kidney as well as brain) and hydrogels (e.g., agarose, polyvinyl alcohol –PVA–, Phytagel –PHY– and methacrylate gelatine –GelMA–) were tested regarding their mechanical properties. For that, viscoelastic behavior, hardness, as well as a non-linear elastic mechanical response were measured. It was seen that there was a significant difference among the results for the different mentioned soft tissues. Some of them appear to be more elastic than viscous as well as being softer or harder. With all this information in mind, a correlation between the mechanical properties of the organs and the different materials was performed. The next conclusions were drawn: (1) to mimic the liver, the best material is 1% wt agarose; (2) to mimic the heart, the best material is 2% wt agarose; (3) to mimic the kidney, the best material is 4% wt GelMA; and (4) to mimic the brain, the best materials are 4% wt GelMA and 1% wt agarose. Neither PVA nor PHY was selected to mimic any of the studied tissues.

Three-dimensional printed moulds to obtain silicone hearts with congenital defects for paediatric heart-surgeon training

OBJECTIVES

Many types of congenital heart disease are amenable to surgical repair or palliation. The procedures are often challenging and require specific surgical training, with limited real-life exposure and often costly simulation options. Our objective was to create realistic and affordable 3D simulation models of the heart and vessels to improve training.

METHODS

We created moulded vessel models using several materials, to identify the material that best replicated human vascular tissue. This material was then used to make more vessels to train residents in cannulation procedures. Magnetic resonance imaging views of a 23-month-old patient with double-outlet right ventricle were segmented using free open-source software. Re-usable moulds produced by 3D printing served to create a silicone model of the heart, with the same material as the vessels, which was used by a heart surgeon to simulate a Rastelli procedure.

RESULTS

The best material was a soft elastic silicone (Shore A hardness 8). Training on the vessel models decreased the residents' procedural time and improved their grades on a performance rating scale. The surgeon evaluated the moulded heart model as realistic and was able to perform the Rastelli procedure on it. Even if the valves were poorly represented, it was found to be useful for preintervention training.

CONCLUSIONS

By using free segmentation software, a relatively low-cost silicone and a technique based on re-usable moulds, the cost of obtaining heart models suitable for training in congenital heart defect surgery can be substantially decreased.

State-of-the-Art Silicone Molded Models for Simulation of Arterial Switch Operation: Innovation with Parting-and-Assembly Strategy

Background

Methods

Results

Conclusions

Role of 3D printing technology in paediatric teaching and training: a systematic review

BACKGROUND

In the UK, undergraduate paediatric training is brief, resulting in trainees with a lower paediatric knowledge base compared with other aspects of medicine. With congenital conditions being successfully treated at childhood, adult clinicians encounter and will need to understand these complex pathologies. Patient-specific 3D printed (3DP) models have been used in clinical training, especially for rarer, complex conditions. We perform a systematic review to evaluate the evidence base in using 3DP models to train paediatricians, surgeons, medical students and nurses.

METHODS

Online databases PubMed, Web of Science and Embase were searched between January 2010 and April 2020 using search terms relevant to "paediatrics", "education", "training" and "3D printing". Participants were medical students, postgraduate trainees or clinical staff. Comparative studies (patient-specific 3DP models vs traditional teaching methods) and non-comparative studies were included. Outcomes gauged objective and subjective measures: test scores, time taken to complete tasks, self-reported confidence and personal preferences on 3DP models. If reported, the cost of and time taken to produce the models were noted.

RESULTS

From 587 results, 15 studies fit the criteria of the review protocol, with 5/15 being randomised controlled studies and 10/15 focussing on cardiovascular conditions. Participants using 3DP models demonstrated improved test scores and faster times to complete procedures and identify anatomical landmarks compared with traditional teaching methods (2D diagrams, lectures, videos and supervised clinical events). User feedback was positive, reporting greater user self-confidence in understanding concepts with users wishing for integrated use of 3DP in regular teaching. Four studies reported the costs and times of production, which varied depending on model complexity and printer. 3DP models were cheaper than 'off-the-shelf' models available on the market and had the benefit of using real-world pathologies. These mostly non-randomised and single-centred studies did not address bias or report long-term or clinically translatable outcomes.

CONCLUSIONS

3DP models were associated with greater user satisfaction and good short-term educational outcomes, with low-quality evidence. Multicentred, randomised studies with long-term follow-up and clinically assessed outcomes are needed to fully assess their benefits in this setting.

PROSPERO REGISTRATION NUMBER

CRD42020179656.

Operative Workflow from CT to 3D Printing of the Heart: Opportunities and Challenges

Medical images do not provide a natural visualization of 3D anatomical structures, while 3D digital models are able to solve this problem. Interesting applications based on these models can be found in the cardiovascular field. The generation of a good-quality anatomical model of the heart is one of the most complex tasks in this context. Its 3D representation has the potential to provide detailed spatial information concerning the heart’s structure, also offering the opportunity for further investigations if combined with additive manufacturing. When investigated, the adaption of printed models turned out to be beneficial in complex surgical procedure planning, for training, education and medical communication. In this paper, we will illustrate the difficulties that may be encountered in the workflow from a stack of Computed Tomography (CT) to the hand-held printed heart model. An important goal will consist in the realization of a heart model that can take into account real wall thickness variability. Stereolithography printing technology will be exploited with a commercial rigid resin. A flexible material will be tested too, but results will not be so satisfactory. As a preliminary validation of this kind of approach, print accuracy will be evaluated by directly comparing 3D scanner acquisitions to the original Standard Tessellation Language (STL) files.

Surgical Simulation in East, Central, and Southern Africa: A Multinational Survey

BACKGROUND

High-income countries have increased the use of simulation-based training and assessment for surgical education. Learners in low- and middle-income countries may have different educational needs and levels of autonomy but they and their patients could equally benefit from the procedural training simulation provides. We sought to characterize the current state of surgical skills simulation in East, Central, and Southern Africa and determine residents' perception and future interest in such activities.

METHODS

A survey was created via collaboration and revision between trainees and educators with experiences spanning high-income countries and low- and middle-income countries. The survey was administered on paper to 76 trainees (PGY2-3) who were completing the College of Surgeons of East, Central, and Southern Africa (COSECSA) Membership of the College of Surgeons examination in Kampala, Uganda in December 2019. Data from paper responses were summarized using descriptive statistics and frequencies.

RESULTS

We received responses from 43 trainees (57%) from 11 countries in sub-Saharan Africa who participated in the examination. Fifty-eight percent of respondents reported having dedicated space for surgical skills simulation training, and most (91%) had participated in some form of simulation activity at some point in their training. However, just 16% used simulation as a regular part of training. The majority of trainees (90%) felt that surgical skills learned in simulation were transferrable to the operating room and agreed it should be a required part of training. Seventy-one percent of trainees felt that simulation could objectively measure technical skills, and 73% percent of respondents agreed that simulation should be integrated into formal assessment. However, residents split on whether proficiency in simulation should be achieved prior to operative experience (54%) and if nontechnical skills could be measured (51%). The most common cited barriers to the integration of surgical simulation into residents' education were lack of suitable tools and models (85%), funding (73%), and maintenance of facilities (49%).

CONCLUSIONS

Residents from East, Central, and Southern Africa strongly agree that simulation is a valuable educational tool and ought to be required during their surgical residency. Barriers to achieving this goal include availability of affordable tools, adequate funding and confidence in the value of the educational experience. Trainees affirm further efforts are necessary to make simulation more widely available in these contexts.

Design and 3D printing of variant pediatric heart models for training based on a single patient scan

Background

3D printed models of pediatric hearts with congenital heart disease have been proven helpful in simulation training of diagnostic and interventional catheterization. However, anatomically accurate 3D printed models are traditionally based on real scans of clinical patients requiring specific imaging techniques, i.e., CT or MRI. In small children both imaging technologies are rare as minimization of radiation and sedation is key. 3D sonography does not (yet) allow adequate imaging of the entire heart for 3D printing. Therefore, an alternative solution to create variant 3D printed heart models for teaching and hands-on training has been established.

Methods

In this study different methods utilizing image processing and computer aided design software have been established to overcome this shortage and to allow unlimited variations of 3D heart models based on single patient scans. Patient-specific models based on a CT or MRI image stack were digitally modified to alter the original shape and structure of the heart. Thereby, 3D hearts showing various pathologies were created. Training models were adapted to training level and aims of hands-on workshops, particularly for interventional cardiology.

Results

By changing the shape and structure of the original anatomy, various training models were created of which four examples are presented in this paper: 1. Design of perimembranous and muscular ventricular septal defect on a heart model with patent ductus arteriosus, 2. Series of heart models with atrial septal defect showing the long-term hemodynamic effect of the congenital heart defect on the right atrial and ventricular wall, 3. Implementation of simplified heart valves and addition of the myocardium to a right heart model with pulmonary valve stenosis, 4. Integration of a constructed 3D model of the aortic valve into a pulsatile left heart model with coarctation of the aorta. All presented models have been successfully utilized and evaluated in teaching or hands-on training courses.

Conclusions

It has been demonstrated that non-patient-specific anatomical variants can be created by modifying existing patient-specific 3D heart models. This way, a range of pathologies can be modeled based on a single CT or MRI dataset. Benefits of designed 3D models for education and training purposes have been successfully applied in pediatric cardiology but can potentially be transferred to simulation training in other medical fields as well.

3D Printing for Medical Applications: Current State of the Art and Perspectives during the COVID-19 Crisis

The coronavirus SARS-CoV-2 pandemic has affected over one hundred million people worldwide and has resulted in over two million deaths. In addition to the toll that coronavirus takes on the health of humans infected with the virus and the potential long term effects of infection, the repercussions of the pandemic on the economy as well as on the healthcare system have been enormous. The global supply of equipment necessary for dealing with the pandemic experienced extreme stress as healthcare systems around the world attempted to acquire personal protective equipment for their workers and medical devices for treating COVID-19. This review describes how 3D printing is currently being used in life saving surgeries such as heart and lung surgery and how 3D printing can address some of the worldwide shortage of personal protective equipment, by examining recent trends of the use of 3D printing and how these technologies can be applied during and after the pandemic. We review the use of 3D printed models for treating the long term effects of COVID-19. We then focus on methods for generating face shields and different types of respirators. We conclude with areas for future investigation and application of 3D printing technology.

The development of a flexible heart model for simulation-based training

OBJECTIVES

Simulation-based training has shown to be effective in training new surgical skills. The objective of this study is to develop a flexible 3-dimensional (3D)-printed heart model that can serve as a foundation for the simulation of multiple cardiovascular procedures.

METHODS

Using a pre-existing digital heart model, 3D transoesophageal echocardiography scans and a thoracic CT scan, a full volume new heart model was developed. The valves were removed from this model, and the internal structures were remodelled to make way for insertable patient-specific structures. Groves at the location of the coronaries were created using extrusion tools in a computer-modelling program. The heart was hollowed to create a more flexible model. A suitable material and thickness was determined using prior test prints. An aortic root and valve was built by segmenting the root from a thoracic CT scan and a valve from a transoesophageal echocardiogram. Segmentations were smoothed, small holes in the valves were filled and surrounding structures were removed to make the objects suitable for 3D printing.

RESULTS

A hollow 3D-printed heart model with the wall thicknesses of 1.5 mm and spaces to insert coronary arteries, valves and aortic roots in various sizes was successfully printed in flexible material.

CONCLUSIONS

A flexible 3D-printed model of the heart was developed onto which patient-specific cardiac structures can be attached to simulate multiple procedures. This model can be used as a platform for surgical simulation of various cardiovascular procedures.

3D-Printing of Drug-Eluting Implants: An Overview of the Current Developments Described in the Literature

The usage of 3D-printing for drug-eluting implants combines the advantages of a targeted local drug therapy over longer periods of time at the precise location of the disease with a manufacturing technique that easily allows modifications of the implant shape to comply with the individual needs of each patient. Research until now has been focused on several aspects of this topic such as 3D-printing with different materials or printing techniques to achieve implants with different shapes, mechanical properties or release profiles. This review is intended to provide an overview of the developments currently described in the literature. The topic is very multifaceted and several of the investigated aspects are not related to just one type of application. Consequently, this overview deals with the topic of 3D-printed drug-eluting implants in the application fields of stents and catheters, gynecological devices, devices for bone treatment and surgical screws, antitumoral devices and surgical meshes, as well as other devices with either simple or complex geometry. Overall, the current findings highlight the great potential of the manufacturing of drug-eluting implants via 3D-printing technology for advanced individualized medicine despite remaining challenges such as the regulatory approval of individualized implants.

3D Printing for Cardiovascular Applications: From End-to-End Processes to Emerging Developments

3D printing as a means of fabrication has seen increasing applications in medicine in the last decade, becoming invaluable for cardiovascular applications. This rapidly developing technology has had a significant impact on cardiovascular research, its clinical translation and education. It has expanded our understanding of the cardiovascular system resulting in better devices, tools and consequently improved patient outcomes. This review discusses the latest developments and future directions of generating medical replicas ('phantoms') for use in the cardiovascular field, detailing the end-to-end process from medical imaging to capture structures of interest, to production and use of 3D printed models. We provide comparisons of available imaging modalities and overview of segmentation and post-processing techniques to process images for printing, detailed exploration of latest 3D printing methods and materials, and a comprehensive, up-to-date review of milestone applications and their impact within the cardiovascular domain across research, clinical use and education. We then provide an in-depth exploration of future technologies and innovations around these methods, capturing opportunities and emerging directions across increasingly realistic representations, bioprinting and tissue engineering, and complementary virtual and mixed reality solutions. The next generation of 3D printing techniques allow patient-specific models that are increasingly realistic, replicating properties, anatomy and function.

Applications of 3D Bio-Printing in Tissue Engineering and Biomedicine

In recent years, 3D bio-printing technology has developed rapidly and become an advanced bio-manufacturing technology. At present, 3D bio-printing technology has been explored in the fields of tissue engineering, drug testing and screening, regenerative medicine and clinical disease research and has achieved many research results. Among them, the application of 3D bio-printing technology in tissue engineering has been widely concerned by researchers, and it contributing many breakthroughs in the preparation of tissue engineering scaffolds. In the future, it is possible to print fully functional tissues or organs by using 3D bio-printing technology which exhibiting great potential development prospects in th applications of organ transplantation and human body implants. It is expected to solve thebiomedical problems of organ shortage and repair of damaged tissues and organs. Besides,3Dbio-printing technology will benefit human beings in more fields. Therefore, this paper reviews the current applications, research progresses and limitations of 3D bio-printing technology in biomedical and life sciences, and discusses the main printing strategies of 3D bio-printing technology. And, the research emphases, possible development trends and suggestions of the application of 3D bio-printing are summarized to provide references for the application research of 3D bio-printing.

At-home hands-on surgical training during COVID19: proof of concept using a virtual telementoring platform

INTRODUCTION

Surgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic.

METHODS

This course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method ¹. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year.

RESULTS

The ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses.

CONCLUSIONS

SAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.

Three-dimensional printing for heart diseases: clinical application review

Heart diseases remain the top threat to human health, and the treatment of heart diseases changes with each passing day. Convincing evidence shows that three-dimensional (3D) printing allows for a more precise understanding of the complex anatomy associated with various heart diseases. In addition, 3D-printed models of cardiac diseases may serve as effective educational tools and for hands-on simulation of surgical interventions. We introduce examples of the clinical applications of different types of 3D printing based on specific cases and clinical application scenarios of 3D printing in treating heart diseases. We also discuss the limitations and clinically unmet needs of 3D printing in this context.

At-home hands-on surgical training during COVID19: proof of concept using a virtual telementoring platform

Introduction

Surgeons in practice have limited opportunities to learn new techniques and procedures. Traditionally, in-person hands-on courses have been the most common means for surgeons to gain exposure to new techniques and procedures. The COVID19 pandemic caused a cessation in these courses and left surgeons with limited opportunities to continue their professional development. Thus, SAGES elected to create an innovative hands-on course that could be completed at home in order to provide surgeons with opportunities to learn new procedures during the pandemic.

Methods

This course was initially planned to be taught as an in-person hands-on course utilizing the Acquisition of Data for Outcomes and Procedure Transfer(ADOPT) method ¹. We identified a virtual telementoring platform, Proximie Ltd(London, UK), and a company that could create a model of an abdominal wall in order to perform a Transversus Abdominis Release, KindHeart™(Chapel Hill, NC, USA). The course consisted of pre-course lectures and videos to be reviewed by participants, a pre-course call to set learning goals, the hands-on telementoring session from home, and monthly webinars for a year.

Results

The ADOPT hands-on hernia course at home was successfully completed on October 23rd of 2020. All participants and faculty were successfully able to set up their model and utilize the telementoring platform, but 15% required assistance. Post course-surveys showed that participants felt that the course was successful in meeting their educational goals and felt similar to prior in-person courses.

Conclusions

SAGES was successfully able to transition and in-person hands-on course to a virtual at-home format. This innovative approach to continuing professional development will be necessary during the times of the COVID19 pandemic, but may be a helpful option for rural surgeons and others with travel restrictions in the future to continue their professional development without the need to travel away from their practice.