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Priya S, La Russa D, Walling A, Goetz S, Hartig T, Khayat A, Gupta P, Nagpal P, Ashwath R. "From Vision to Reality: Virtual Reality's Impact on Baffle Planning in Congenital Heart Disease". Pediatr Cardiol 2024; 45:165-174. [PMID: 37932525 DOI: 10.1007/s00246-023-03323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/04/2023] [Indexed: 11/08/2023]
Abstract
This study aims to evaluate the feasibility and utility of virtual reality (VR) for baffle planning in congenital heart disease (CHD), specifically by creating patient-specific 3D heart models and assessing a user-friendly VR interface. Patient-specific 3D heart models were created using high-resolution imaging data and a VR interface was developed for baffle planning. The process of model creation and the VR interface were assessed for their feasibility, usability, and clinical relevance. Collaborative and interactive planning within the VR space were also explored. The study findings demonstrate the feasibility and usefulness of VR in baffle planning for CHD. Patient-specific 3D heart models generated from imaging data provided valuable insights into complex spatial relationships. The developed VR interface allowed clinicians to interact with the models, simulate different baffle configurations, and assess their impact on blood flow. The VR space's collaborative and interactive planning enhanced the baffle planning process. This study highlights the potential of VR as a valuable tool in baffle planning for CHD. The findings demonstrate the feasibility of using patient-specific 3D heart models and a user-friendly VR interface to enhance surgical planning and patient outcomes. Further research and development in this field are warranted to harness the full benefits of VR technology in CHD surgical management.
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Affiliation(s)
- Sarv Priya
- Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Dan La Russa
- Realize Medical Inc., Ottawa, Canada
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, Canada
| | - Abigail Walling
- Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Sawyer Goetz
- Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Tyler Hartig
- Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | | | - Pankaj Gupta
- Division of Pediatric Cardiology, The Royal Hospital for Children, Glasgow, UK
| | - Prashant Nagpal
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Ravi Ashwath
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Ullah M, Bibi A, Wahab A, Hamayun S, Rehman MU, Khan SU, Awan UA, Riaz NUA, Naeem M, Saeed S, Hussain T. Shaping the Future of Cardiovascular Disease by 3D Printing Applications in Stent Technology and its Clinical Outcomes. Curr Probl Cardiol 2024; 49:102039. [PMID: 37598773 DOI: 10.1016/j.cpcardiol.2023.102039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/22/2023]
Abstract
Cardiovascular disease (CVD) is a leading cause of death worldwide. In recent years, 3D printing technology has ushered in a new era of innovation in cardiovascular medicine. 3D printing in CVD management encompasses various aspects, from patient-specific models and preoperative planning to customized medical devices and novel therapeutic approaches. In-stent technology, 3D printing has revolutionized the design and fabrication of intravascular stents, offering tailored solutions for complex anatomies and individualized patient needs. The advantages of 3D-printed stents, such as improved biocompatibility, enhanced mechanical properties, and reduced risk of in-stent restenosis. Moreover, the clinical trials and case studies that shed light on the potential of 3D printing technology to improve patient outcomes and revolutionize the field has been comprehensively discussed. Furthermore, regulatory considerations, and challenges in implementing 3D-printed stents in clinical practice are also addressed, underscoring the need for standardization and quality assurance to ensure patient safety and device reliability. This review highlights a comprehensive resource for clinicians, researchers, and policymakers seeking to harness the full potential of 3D printing technology in the fight against CVD.
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Affiliation(s)
- Muneeb Ullah
- Department of Pharmacy, Kohat University of Science, and technology (KUST), Kohat, Khyber Pakhtunkhwa, Pakistan
| | - Ayisha Bibi
- Department of Pharmacy, Kohat University of Science, and technology (KUST), Kohat, Khyber Pakhtunkhwa, Pakistan
| | - Abdul Wahab
- Department of Pharmacy, Kohat University of Science, and technology (KUST), Kohat, Khyber Pakhtunkhwa, Pakistan
| | - Shah Hamayun
- Department of Cardiology, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan
| | - Mahboob Ur Rehman
- Department of Cardiology, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan
| | - Shahid Ullah Khan
- Department of Biochemistry, Women Medical and Dental College, Khyber Medical University, Abbottabad, Khyber Pakhtunkhwa, Pakistan.
| | - Uzma Azeem Awan
- Department of Biological Sciences, National University of Medical Sciences (NUMS) Rawalpindi, Rawalpindi, Punjab, Pakistan
| | - Noor-Ul-Ain Riaz
- Department of Pharmacy, Kohat University of Science, and technology (KUST), Kohat, Khyber Pakhtunkhwa, Pakistan
| | - Muhammad Naeem
- Department of Biological Sciences, National University of Medical Sciences (NUMS) Rawalpindi, Rawalpindi, Punjab, Pakistan.
| | - Sumbul Saeed
- School of Environment and Science, Griffith University, Nathan, Queensland, Australia
| | - Talib Hussain
- Women Dental College Abbottabad, Abbottabad, Khyber Pakhtunkhwa, Pakistan
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Valls-Esteve A, Lustig-Gainza P, Adell-Gomez N, Tejo-Otero A, Englí-Rueda M, Julian-Alvarez E, Navarro-Sureda O, Fenollosa-Artés F, Rubio-Palau J, Krauel L, Munuera J. A state-of-the-art guide about the effects of sterilization processes on 3D-printed materials for surgical planning and medical applications: A comparative study. Int J Bioprint 2023; 9:756. [PMID: 37555083 PMCID: PMC10406103 DOI: 10.18063/ijb.756] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/01/2023] [Indexed: 08/10/2023] Open
Abstract
Surgeons use different medical devices in the surgery, such as patient-specific anatomical models, cutting and positioning guides, or implants. These devices must be sterilized before being used in the operation room. There are many sterilization processes available, with autoclave, hydrogen peroxide, and ethylene oxide being the most common in hospital settings. Each method has both advantages and disadvantages in terms of mechanics, chemical interaction, and post-treatment accuracy. The aim of the present study is to evaluate the dimensional and mechanical effect of the most commonly used sterilization techniques available in clinical settings, i.e., Autoclave 121, Autoclave 134, and hydrogen peroxide (HPO), on 11 of the most used 3D-printed materials fabricated using additive manufacturing technologies. The results showed that the temperature (depending on the sterilization method) and the exposure time to that temperature influence not only the mechanical behavior but also the original dimensioning planned on the 3D model. Therefore, HPO is a better overall option for most of the materials evaluated. Finally, based on the results of the study, a recommendation guide on sterilization methods per material, technology, and clinical application is presented.
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Affiliation(s)
- Arnau Valls-Esteve
- Innovation Department, Hospital Sant Joan de Déu,
Esplugues de Llobregat, Spain
- Medicina i Recerca Translacional, Facultat de Medicina i
Ciències de la Salut, Universitat de Barcelona, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
| | | | - Nuria Adell-Gomez
- Innovation Department, Hospital Sant Joan de Déu,
Esplugues de Llobregat, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
| | - Aitor Tejo-Otero
- Centre CIM, Universitat Politècnica de Catalunya
(CIM UPC), Barcelona, Spain
| | - Marti Englí-Rueda
- Innovation Department, Hospital Sant Joan de Déu,
Esplugues de Llobregat, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
| | | | - Osmeli Navarro-Sureda
- Sterilization Department, Hospital Sant Joan de Déu,
Universitat de Barcelona, Spain
| | - Felip Fenollosa-Artés
- Centre CIM, Universitat Politècnica de Catalunya
(CIM UPC), Barcelona, Spain
- Department of Mechanical Engineering, School of Engineering
of Barcelona (ETSEIB), Universitat Politècnica de Catalunya, Barcelona,
Spain
| | - Josep Rubio-Palau
- Medicina i Recerca Translacional, Facultat de Medicina i
Ciències de la Salut, Universitat de Barcelona, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
- Department of Pediatric Surgery, Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
- Maxillofacial Unit, Department of Pediatric Surgery,
Hospital Sant Joan de Déu, Universitat de Barcelona, Spain
| | - Lucas Krauel
- Medicina i Recerca Translacional, Facultat de Medicina i
Ciències de la Salut, Universitat de Barcelona, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
- Department of Pediatric Surgery, Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
| | - Josep Munuera
- Medicina i Recerca Translacional, Facultat de Medicina i
Ciències de la Salut, Universitat de Barcelona, Spain
- 3D for Health Unit (3D4H), Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
- Department of Diagnostic Imaging, Hospital Sant Joan de
Déu, Universitat de Barcelona, Spain
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Candelari M, Cappello IA, Pannone L, Monaco C, Talevi G, Bori E, Ramak R, La Meir M, Gharaviri A, Chierchia GB, Innocenti B, de Asmundis C. A 3D-printed surgical guide for ischemic scar targeting and ablation. Front Cardiovasc Med 2022; 9:1029816. [PMID: 36465435 PMCID: PMC9715585 DOI: 10.3389/fcvm.2022.1029816] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/31/2022] [Indexed: 09/19/2023] Open
Abstract
Background 3D printing technology development in medical fields allows to create 3D models to assist preoperative planning and support surgical procedures. Cardiac ischemic scar is clinically associated with malignant arrhythmias. Catheter ablation is aimed at eliminating the arrhythmogenic tissue until the sinus rhythm is restored. The scope of this work is to describe the workflow for a 3D surgical guide able to define the ischemic scar and target catheter ablation. Materials and methods For the patient-specific 3D surgical guide and 3D heart phantom model realization, both CT scan and cardiac MRI images were processed; this was necessary to extract anatomical structures and pathological information, respectively. Medical images were uploaded and processed in 3D Slicer. For the surgical guide modeling, images from CT scan and MRI were loaded in Meshmixer and merged. For the heart phantom realization, only the CT segmentation was loaded in Meshmixer. The surgical guide was printed in MED625FLX with Polyjet technology. The heart phantom was printed in polylactide with FDM technology. Results 3D-printed surgical model was in agreement with prespecified imputed measurements. The phantom fitting test showed high accuracy of the 3D surgical tool compared with the patient-specific reproduced heart. Anatomical references in the surgical guide ensured good stability. Ablation catheter fitting test showed high suitability of the guide for different ablation tools. Conclusion A 3D-printed guide for ventricular tachycardia ablation is feasible and accurate in terms of measurements, stability, and geometrical structure. Concerning clinical use, further clinical investigations are eagerly awaited.
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Affiliation(s)
- Mara Candelari
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Ida Anna Cappello
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Cinzia Monaco
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Giacomo Talevi
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Edoardo Bori
- BEAMS Department (Bio Electro and Mechanical Systems), Université Libre de Bruxelles, Brussels, Belgium
| | - Robbert Ramak
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Ali Gharaviri
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Gian Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
| | - Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), Université Libre de Bruxelles, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel–Vrije Universiteit Brussel, Brussels, Belgium
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Talevi G, Pannone L, Monaco C, Bori E, Cappello IA, Candelari M, Ramak R, La Meir M, Gharaviri A, Chierchia GB, Innocenti B, de Asmundis C. Development of a 3D printed surgical guide for Brugada syndrome substrate ablation. Front Cardiovasc Med 2022; 9:1029685. [DOI: 10.3389/fcvm.2022.1029685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022] Open
Abstract
BackgroundBrugada syndrome (BrS) is a disease associated with ventricular arrhythmias and sudden cardiac death. Epicardial ablation has demonstrated high therapeutic efficacy in preventing ventricular arrhythmias. The purpose of this research is to define a workflow to create a patient-specific 3D-printed tool to be used as a surgical guide for epicardial ablation in BrS.MethodsDue to their mechanical properties and biocompatibility, the MED625FLX and TPU95A were used for cardiac 3D surgical guide printing. ECG imaging was used to define the target region on the right ventricular outflow tract (RVOT). CT scan imaging was used to design the model based on patient anatomy. A 3D patient-specific heart phantom was also printed for fitting test. Sterilization test was finally performed.Results3D printed surgical models with both TPU95A and MED625FLX models were in agreement with pre-specified imputed measurements. The phantom test showed retention of shape and correct fitting of the surgical tool to the reproduced phantom anatomy, as expected, for both materials. The surgical guide adapted to both the RVOT and the left anterior descending artery. Two of the 3D models produced in MED265FLX showed damage due to the sterilization process.ConclusionsA 3D printed patient-specific surgical guide for epicardial substrate ablation in BrS is feasible if a specific workflow is followed. The design of the 3D surgical guide ensures proper fitting on the heart phantom with good stability. Further investigations for clinical use are eagerly awaited.
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Cappello IA, Candelari M, Pannone L, Monaco C, Bori E, Talevi G, Ramak R, La Meir M, Gharaviri A, Chierchia GB, Innocenti B, de Asmundis C. Temperature analysis of 3D-printed biomaterials during unipolar and bipolar radiofrequency ablation procedure. Front Cardiovasc Med 2022; 9:978333. [PMID: 36186978 PMCID: PMC9515363 DOI: 10.3389/fcvm.2022.978333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Due to their mechanical properties, the MED625FLX and TPU95A could be appropriate candidates for cardiac 3D surgical guide use during radiofrequency ablation (RFA) treatment. Methods RFA aims to destroy the heart tissue, which cause arrhythmias, by applying a radiofrequency (RF) energy at critical temperature above +50.0°C, where the thermal damage is considered not reversible. This study aims to analyze the biomaterials thermal properties with different thicknesses, by testing the response to bipolar and unipolar RFA on porcine muscle samples (PMS), expressed in temperature. For the materials evaluation, the tissue temperature during RFA applications was recorded, firstly without (control) and after with the biomaterials in position. The biomaterials were considered suitable for the RFA treatment if: (1) the PMS temperatures with the samples were not statistically different compared with the control; (2) the temperatures never reached the threshold; (3) no geometrical changes after RFA were observed. Results Based on these criteria, none of the tested biomaterials resulted appropriate for unipolar RFA and the TPU95A failed almost all thermal tests also with the bipolar RFA. The 1.0 mm MED625FLX was modified by bipolar RFA in shape, losing its function. Instead, the 2.5 mm MED625FLX was considered suitable for bipolar RFA catheter use only. Conclusions The 2.5 mm MED625FLX could be used, in the design of surgical guides for RFA bipolar catheter only, because of mechanical, geometrical, and thermal properties. None of biomaterials tested are appropriate for unipolar ablation catheter because of temperature concerns. Further investigations for clinical use are eagerly awaited.
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Affiliation(s)
- Ida Anna Cappello
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Mara Candelari
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Cinzia Monaco
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Edoardo Bori
- BEAMS Department (Bio Electro and Mechanical Systems), Université Libre de Bruxelles, Brussels, Belgium
| | - Giacomo Talevi
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Robbert Ramak
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Ali Gharaviri
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Gian Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), Université Libre de Bruxelles, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- *Correspondence: Carlo de Asmundis ;
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CT-Derived 3D Printing for Coronary Artery Cannulation Simulator Design Manufacturing. Bioengineering (Basel) 2022; 9:bioengineering9080338. [PMID: 35892751 PMCID: PMC9330152 DOI: 10.3390/bioengineering9080338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022] Open
Abstract
Mastering coronary angiography requires practice. Cadavers and animals do not accurately represent the human anatomical body, and practicing with actual patients has medical safety issues. Simulation offers safe and realistic conditions for cardiology intervention training. In this study, we propose a novel 3D printed simulator that contains physically realistic anatomy and has four access points. It increases safety for patients and students, and production is low-cost. We aimed to make and validate this simulator design as a prototype for coronary cannulation training. It was designed using computed tomography (CT) scan data of aorta, coronary, and heart models, and was printed by 3D printing with resin materials consisting of 75% or 85% clear resin and 25% or 15% flexible resin additive. The simulator was constructed with a camera above the simulator with a degree of LAO of 30°/0°, a display table, and an acrylic box. Twelve validators were interviewed for their expert opinions and analyzed by a qualitative method. They scored the simulator’s suitability on a four-point Likert scale questionnaire. They described the simulator as having admirable values for all aspects (85.8%), curriculum suitability (92%), educational importance (94%), accuracy (83%), efficiency (78%), safety (87.5%), endurance (81.2%), aesthetics (80.7%), storage (85.4%), and affordability (85.8%).
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