Three Dimensional Printing: Applications in Surgery for Congenital Heart Disease

An impact of three dimensional techniques in virtual reality

Three dimensional (3D) imaging play a prominent role in the diagnosis, treatment planning, and post-therapeutic monitoring of patients with Rheumatic Heart Disease (RHD) or mitral valve disease. More interactive and realistic medical experiences take an advantage of advanced visualization techniques like augmented, mixed, and virtual reality to analyze the 3D models. Further, 3D printed mitral valve model is being used in medical field. All these technologies improve the understanding of the complex morphologies of mitral valve disease. Real-time 3D Echocardiography has attracted much more attention in medical researches because it provides interactive feedback to acquire high-quality images as well as timely spatial information of the scanned area and hence is necessary for intraoperative ultrasound examinations. In this article, three dimensional techniques and its impacts in mitral valve disease are reviewed. Specifically, the data acquisition techniques, reconstruction algorithms with clinical applications are presented. Moreover, the advantages and disadvantages of state-of-the-art approaches are discussed in detail.

Single-center experience with routine clinical use of 3D technologies in surgical planning for pediatric patients with complex congenital heart disease

PURPOSE

This study was planned to assess the application of three-dimensional (3D) cardiac modeling in preoperative evaluation for complex congenital heart surgeries.

METHODS

From July 2015 to September 2019, 18 children diagnosed with complex congenital heart diseases (CHDs) were enrolled in this study (double outlet right ventricle in nine patients, complex types of transposition of the great arteries in six patients, congenitally corrected transposition of the great arteries in two patients, and univentricular heart in one patient). The patients' age ranged from 7 months to 19 years (median age, 14 months). Before the operation, 3D patient-specific cardiac models were created based on computed tomography (CT) data. Using each patient's data, a virtual computer model (3D mesh) and stereolithographic (SLA) file that would be printed as a 3D model were generated. These 3D cardiac models were used to gather additional data about cardiac anatomy for presurgical decision-making.

RESULTS

All 18 patients successfully underwent surgeries, and there were no mortalities. The 3D patient-specific cardiac models led to a change from the initial surgical plans in 6 of 18 cases (33%), and biventricular repair was considered feasible. Moreover, the models helped to modify the planned biventricular repair in five cases, for left ventricular outflow tract obstruction removal and ventricular septal defect enlargement. 3D cardiac models enable pediatric cardiologists to better understand the spatial relationships between the ventricular septal defect and great vessels, and they help surgeons identify risk structures more clearly for detailed planning of surgery. There was a strong correlation between the models of the patients and the anatomy encountered during the operation.

CONCLUSION

3D cardiac models accurately reveal the patient's anatomy in detail and are therefore beneficial for planning surgery in patients with complex intracardiac anatomy.

Virtual museum of congenital heart defects: digitization and establishment of a database for cardiac specimens

Education and training of morphology for medical students, and professionals specializing in pediatric cardiology and surgery has traditionally been based on hands-on encounter with congenitally malformed cardiac specimens. Large international archives are no longer widely available due to stricter data protection rules, a reduced number of autopsies, attrition rate of existing specimens, and most importantly due to a higher survival rate of patients. Our Cardiac Archive houses about 400 cardiac specimens with congenital heart disease. The collection spans almost 60 years and thus goes back to pre-surgical era. Unfortunately, attrition rate due to desiccation has led to an increased natural decay in recent years. The present multi-institutional project focuses on saving the collection by digitization. Specimens are scanned by high-resolution micro-CT/MRI. Virtual 3D-models are segmented and a comprehensive database is built. We now report an initial feasibility study with six test specimens that provided promising results, however, adequate presentation of the intracardiac anatomy, including septa and cardiac valves requires further refinements. Computer assisted design methods are necessary to overcome consequences of pathological examination, shrinkage and/or distortion of the specimens. For a next step, we anticipate an expandable web-based virtual museum with interactive reference and training tools. Web access for professional third parties will be provided by registration/subscription. In a future phase, segmental wall motion data could be added to virtual models. 3D-printed models may replace actual specimens and serve as hands-on surgical training to elucidate complex morphologies, promote surgical emulation, and extract more accurate procedural knowledge based on such a collection.

3D printing for congenital heart disease: a single site's initial three-yearexperience

Background

3D printing is an ideal manufacturing process for creating patient-matched models (anatomical models) for surgical and interventional planning. Cardiac anatomical models have been described in numerous case studies and journal publications. However, few studies attempt to describe wider impact of the novel planning augmentation tool. The work here presents the evolution of an institution’s first 3 full years of 3D prints following consistent integration of the technology into clinical workflow (2012–2014) - a center which produced 79 models for surgical planning (within that time frame). Patient outcomes and technology acceptance following implementation of 3D printing were reviewed.

Methods

A retrospective analysis was designed to investigate the anatomical model’s impact on time-based surgical metrics. A contemporaneous cohort of standard-of-care pre-procedural planning (no anatomical models) was identified for comparative analysis. A post-surgery technology acceptance assessment was also employed in a smaller subset to measure perceived efficacy of the anatomical models. The data was examined.

Results

Within the timeframe of the study, 928 primary-case cardiothoracic surgeries (encompassing both CHD and non-CHD surgeries) took place at the practicing pediatric hospital. One hundred sixty four anatomical models had been generated for various purposes. An inclusion criterion based on lesion type limited those with anatomic models to 33; there were 113 cases matching the same criterion that received no anatomical model. Time-based metrics such as case length-of-time showed a mean reduction in overall time for anatomical models. These reductions were not statistically significant. The technology acceptance survey did demonstrate strong perceived efficacy. Anecdotal vignettes further support the technology acceptance.

Discussion & conclusion

The anatomical models demonstrate trends for reduced operating room and case length of time when compared with similar surgeries in the same time-period; in turn, these reductions could have significant impact on patient outcomes and operating room economics. While analysis did not yield robust statistical powering, strong Cohen’s d values suggest poor powering may be more related to sample size than non-ideal outcomes. The utility of planning with an anatomical model is further supported by the technology acceptance study which demonstrated that surgeons perceive the anatomical models to be an effective tool in surgical planning for a complex CHD repair. A prospective multi-center trial is currently in progress to further validate or reject these findings.

Three-dimensional printing: changing clinical care or just a passing fad?

PURPOSE OF REVIEW

Advances in medical imaging and three-dimensional (3D) reconstruction software have enabled a proliferation of 3D modeling and 3D printing for clinical applications. In particular, 3D printing has garnered an extraordinary media presence over the past few years. There is growing optimism that 3D printing can address patient specificity and complexity for improved interventional and surgical planning. Will this relatively untested technology bring about a paradigm shift in the clinical environment, or is it just a transient fad?

RECENT FINDINGS

Case studies and series centered around 3D printing are omnipresent in clinical and engineering journals. These primarily qualitative studies support the potential efficacy of the emerging technology. Few studies analyze the value of 3D printing, weighing its potential benefits against increasing costs (e.g., institutional overhead, labor, and materials).

SUMMARY

Clinical integration of 3D printing is growing rapidly, and its adoption into clinical practice presents unique workflow challenges. There are numerous clinical trials on the horizon that will finally help to elucidate the measured impact of 3D printing on clinical outcomes through quantitative analyses of clinical and economic metrics. The contrived integration of 3D printing into clinical practice seems all but certain as the value of this technology becomes more and more evident.

Use of Three-dimensional Printing in Orthopaedic Surgical Planning

Background

Three-dimensional (3D) printing is a technique based on overlapping layers of a material (eg, plastic, clay, and metal). The widespread implementation of 3D printers has resulted in a notable increase in use. Fields such as construction, engineering, and medicine benefit from this technique.

Aim

The use of 3D printed scale models permits better surgical planning and results.

Methods

The models were created based on CT images of seven patients (age range, 5 to 61 years) with different pathologies who were candidates for surgery.

Results

Surgical time decreased as a result of detailed surgical planning with printed models. This technique also was associated with a decrease in bleeding, a reduction in the amount of anesthesia required, and greater precision. In some patients, a change in surgical strategy was noted, thus allowing for a reduction in the number of surgeries and the aggressiveness of surgery. Finally, the preoperative practice (virtual and physical osteotomies using cutting tools) that was performed in two cases allowed the surgeon to evaluate the different approach alternatives and establish the best strategy.

Conclusions

The use of 3D-printed anatomic models has improved surgical planning, especially for patients in whom the conventional techniques are insufficient for establishing a proper strategy. The extra information provided by 3D-printed models can lead to a better intervention strategy, which is beneficial for patients because it decreases the risks, procedure times, and recovery times.

Three-dimensional modelling and three-dimensional printing in pediatric and congenital cardiac surgery

Three-dimensional (3D) modelling and printing methods greatly support advances in individualized medicine and surgery. In pediatric and congenital cardiac surgery, personalized imaging and 3D modelling presents with a range of advantages, e.g., better understanding of complex anatomy, interactivity and hands-on approach, possibility for preoperative surgical planning and virtual surgery, ability to assess expected results, and improved communication within the multidisciplinary team and with patients. 3D virtual and printed models often add important new anatomical findings and prompt alternative operative scenarios. For the lack of critical mass of evidence, controlled randomized trials, however, most of these general benefits remain anecdotal. For an individual surgical case-scenario, prior knowledge, preparedness and possibility of emulation are indispensable in raising patient-safety. It is advocated that added value of 3D printing in healthcare could be raised by establishment of a multidisciplinary centre of excellence (COE). Policymakers, research scientists, clinicians, as well as health care financers and local entrepreneurs should cooperate and communicate along a legal framework and established scientific guidelines for the clinical benefit of patients, and towards financial sustainability. It is expected that besides the proven utility of 3D printed patient-specific anatomical models, 3D printing will have a major role in pediatric and congenital cardiac surgery by providing individually customized implants and prostheses, especially in combination with evolving techniques of bioprinting.

Toward a patient-specific tissue engineered vascular graft

Integrating three-dimensional printing with the creation of tissue-engineered vascular grafts could provide a readily available, patient-specific, autologous tissue source that could significantly improve outcomes in newborns with congenital heart disease. Here, we present the recent case of a candidate for our tissue-engineered vascular graft clinical trial deemed ineligible due to complex anatomical requirements and consider the application of three-dimensional printing technologies for a patient-specific graft. We 3D-printed a closed-disposable seeding device and validated that it performed equivalently to the traditional open seeding technique using ovine bone marrow–derived mononuclear cells. Next, our candidate’s preoperative imaging was reviewed to propose a patient-specific graft. A seeding apparatus was then designed to accommodate the custom graft and 3D-printed on a commodity fused deposition modeler. This exploratory feasibility study represents an important proof of concept advancing progress toward a rationally designed patient-specific tissue-engineered vascular graft for clinical application.

Role of virtual reality in congenital heart disease

OBJECTIVE

New platforms for patient imaging present opportunities for improved surgical planning in complex congenital heart disease (CHD). Virtual reality (VR) allows for interactive manipulation of high-resolution representations of patient-specific imaging data, as a supplement to traditional 2D visualizations and 3D printed heart models.

DESIGN

We present the novel use of VR for the presurgical planning of cardiac surgery in two infants with complex CHD to demonstrate interactive real-time views of complex intra and extracardiac anatomy.

RESULTS

The use of VR for cardiac presurgical planning is feasible using existing imaging data. The software was evaluated by both pediatric cardiac surgeons and pediatric cardiologists, and felt to be reliable and operated with a very short learning curve.

CONCLUSIONS

VR with controller-based interactive capability allows for interactive viewing of 3D models with complex intra and extracardiac anatomy. This serves as a useful complement to traditional preoperative planning methods in terms of its potential for group based collaborative discussion, user defined illustrative views, cost-effectiveness, and facility of use.

Use of 3D models of vascular rings and slings to improve resident education

OBJECTIVE

Three-dimensional (3D) printing is a manufacturing method by which an object is created in an additive process, and can be used with medical imaging data to generate accurate physical reproductions of organs and tissues for a variety of applications. We hypothesized that using 3D printed models of congenital cardiovascular lesions to supplement an educational lecture would improve learners' scores on a board-style examination.

DESIGN AND INTERVENTION

Patients with normal and abnormal aortic arches were selected and anonymized to generate 3D printed models. A cohort of pediatric and combined pediatric/emergency medicine residents were then randomized to intervention and control groups. Each participant was given a subjective survey and an objective board-style pretest. Each group received the same 20-minutes lecture on vascular rings and slings. During the intervention group's lecture, 3D printed physical models of each lesion were distributed for inspection. After each lecture, both groups completed the same subjective survey and objective board-style test to assess their comfort with and postlecture knowledge of vascular rings.

RESULTS

There were no differences in the basic demographics of the two groups. After the lectures, both groups' subjective comfort levels increased. Both groups' scores on the objective test improved, but the intervention group scored higher on the posttest.

CONCLUSIONS

This study demonstrated a measurable gain in knowledge about vascular rings and pulmonary artery slings with the addition of 3D printed models of the defects. Future applications of this teaching modality could extend to other congenital cardiac lesions and different learners.

Three-dimensional-printed cardiac prototypes aid surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases: Early experience and proof of concept in a resource-limited environment

Introduction:

Three-dimensional. (3D) printing is an innovative manufacturing process that allows computer-assisted conversion of 3D imaging data into physical “printouts” Healthcare applications are currently in evolution.

Objective:

The objective of this study was to explore the feasibility and impact of using patient-specific 3D-printed cardiac prototypes derived from high-resolution medical imaging data (cardiac magnetic resonance imaging/computed tomography [MRI/CT]) on surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases (CHDs).

Materials and Methods:

Five patients with complex CHD with previously unresolved management decisions were chosen. These included two patients with complex double-outlet right ventricle, two patients with criss-cross atrioventricular connections, and one patient with congenitally corrected transposition of great arteries with pulmonary atresia. Cardiac MRI was done for all patients, cardiac CT for one; specific surgical challenges were identified. Volumetric data were used to generate patient-specific 3D models. All cases were reviewed along with their 3D models, and the impact on surgical decision-making and preoperative planning was assessed.

Results:

Accurate life-sized 3D cardiac prototypes were successfully created for all patients. The models enabled radically improved 3D understanding of anatomy, identification of specific technical challenges, and precise surgical planning. Augmentation of existing clinical and imaging data by 3D prototypes allowed successful execution of complex surgeries for all five patients, in accordance with the preoperative planning.

Conclusions:

3D-printed cardiac prototypes can radically assist decision-making, planning, and safe execution of complex congenital heart surgery by improving understanding of 3D anatomy and allowing anticipation of technical challenges.

The Interactive Use of Multi-Dimensional Modeling and 3D Printing in Preplanning of Type A Aortic Dissection

We report a technique of multidimensional modeling and 3D printing in preplanning of Type A acute aortic dissection (TAAD) repair. doi: 10.1111/jocs.12772 (J Card Surg 2016;31:441-445).