|Year : 2019 | Volume
| Issue : 4 | Page : 129-132
Personalized three-dimensional printed models assist presurgical planning and treatment of complex congenital heart disease
Zhonghua Sun1, Sultan Aldosari2
1 Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, Perth, Australia
2 Department of Medical Imaging, King Saud Medical City, Riyadh, Saudi Arabia
|Date of Submission||21-Oct-2019|
|Date of Decision||28-Oct-2019|
|Date of Acceptance||12-Nov-2019|
|Date of Web Publication||13-Apr-2020|
Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, Perth
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sun Z, Aldosari S. Personalized three-dimensional printed models assist presurgical planning and treatment of complex congenital heart disease. Digit Med 2019;5:129-32
|How to cite this URL:|
Sun Z, Aldosari S. Personalized three-dimensional printed models assist presurgical planning and treatment of complex congenital heart disease. Digit Med [serial online] 2019 [cited 2020 Aug 7];5:129-32. Available from: http://www.digitmedicine.com/text.asp?2019/5/4/129/282367
Three-dimensional (3D) printing is increasingly used in medical applications ranging from original dominance in maxillofacial and orthopedic surgeries to tumor imaging and cardiovascular disease.,,,,,,,,,, Patient-specific 3D-printed models created from medical imaging data, mainly from computed tomography (CT) and magnetic resonance imaging (MRI), have been shown to accurately replicate normal anatomical structures and pathologies.,,,,, One of the rapidly expanding areas of 3D printing in medicine lies in cardiovascular disease, in particular in congenital heart disease (CHD). The complexity of cardiac structures and various disease patterns of CHD present challenges for accurate assessment of disease extent based on traditional two-dimensional or 3D views on computer screens. This limitation can be overcome by use of 3D-printed heart models to a greater extent.,,,,
A recent systematic review and meta-analysis have summarized the usefulness of 3D printing in CHD in the following areas: medical education, communication between cardiologists/cardiac surgeons and patients or parents of patients, intraoperative orientation, presurgical planning, and simulation. Of these applications, the clinical value of 3D-printed heart models in presurgical planning and simulation of complex CHD patients is showing promise, although only a few studies are available in the current literature.,, A recent study by Vettukattil et al. provided further evidence of how 3D-printed models improved surgical treatment in patients with complex CHD. Despite the inclusion of only five cases in this report, results of this single-center experience highlighted the added value of using 3D-printed personalized models in assisting the management of complex CHD patients.
There are three observations from Vettukattil's study that bear discussion. First, these five cases all have complex CHD with each patient undergoing at least two surgical operations. Complex cardiac pathologies including atrioventricular septal defect, double outlet right ventricle, bilateral superior vena cava, and hypoplastic right ventricle were present in most of these cases in this study. This emphasizes the complicated cardiac conditions and challenges of managing these patients based on traditional imaging approaches for preoperative planning of cardiac surgeries. This is consistent with findings of a randomized controlled trial showing that 3D-printed heart models improved pediatric residents' confidence in managing complex CHD but with no benefits in understanding simple CHD such as ventricular septal defect when compared to the traditional education of using lectures.
Second, 3D-printed heart models from either cardiac CT or MRI images were used by the multi-disciplinary team to develop possible and most appropriate surgical approach for treating these CHD patients [Figure 1] and [Figure 2]. This provides further evidence about the clinical application of 3D printing in CHD as most of the current reports focus on 3D printing in medical education and doctor–patient communication with regarding to improvement in understanding of the complex cardiac structures in relation to the pathologies.,,,, Valverde et al., in their multicenter study, provided the convincing results of using 3D-printed models in treating patients with complex CHD. Of 40 patients with CHD enrolled from 10 international centers, 3D-printed models were found to have a significant impact on patient management by redefining surgical approach in nearly 50% cases. The surgical plan was modified in 25% of cases after inspecting the 3D-printed models, leading to the change from conservative management to surgery. In spite of case report limitation in the Vettukattil's study, authors highlighted how 3D-printed models assisted management of these complex CHD cases which were previously thought not to be successfully treated. The high accuracy and tactile nature of these 3D-printed models improve surgeons' understanding of individual case's anatomy and pathology, thus achieving the goal of precision medicine.
|Figure 1: An 11-year-old male patient with AVSD, dextrocardia, double outlet right ventricle, bilateral superior vena cava and mixed total anomalous pulmonary venous connection. (a) Virtual model derived from cardiac computed tomography demonstrating the relationship between the unbalanced atrioventricular septal defect (encircled), ventricles, and outflow tracts. (b) Clear rigid 3D-printed model being utilized during multi-disciplinary team meeting to discuss the possible surgical approach. 3D: Three-dimensional, Ao: Aorta, AVSD: Atrioventricular septal defect, IVC: Inferior vena cava, LLPV: Left lower pulmonary vein, LSVC: Left superior vena cava, LV: Left ventricle, MPA: Main pulmonary artery, RCA: Right coronary artery, RPA: Right pulmonary artery, RV: Right ventricle. Reprinted with permission from Vettukattil et al.|
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|Figure 2: A 26-year-old male with large atrial septal defect and pulmonary atresia with intact ventricular septum. (a) Virtual model demonstrating mid-cavitary obstruction of the right ventricle by hypertrophied muscle bundles. (b) Flexible 3D-printed model being used for patient education during postsurgical follow-up visit. 3D: Three-dimensional, Ao: Aorta, PA: Pulmonary artery, RA: Right ventricle, RV: Right ventricle, TV: Tricuspid valve. Reprinted with permission from Vettukattil et al.|
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Third, similar to other studies reporting 3D printing in cardiovascular disease; this study suffers from a very sample size as it only includes 5 CHD cases. According to recent systematic reviews on 3D printing in CHD, more than half of the current studies are represented by case reports or case series, which is the main limitation of 3D printing in CHD., With more research being conducted at different sites, we are expecting more studies with the inclusion of larger sample size and robust findings in the near future, given the impact of 3D printing in treating CHD patients. Another area that deserves to be investigated lies in the assessment of clinical outcomes when 3D-printed models are incorporated into the surgical planning of CHD patients. There is a lack of research on studying how 3D-printed heart models contribute to reductions on surgery-related risks and complications when compared to the standard approach. Further, the cost-effectiveness of 3D printing should also be investigated with regard to the practicability of this fast-evolving technology in managing complex CHD patients.
In summary, this case report emphasizes the clinical impact of 3D printing in surgical planning and treatment of patients with complex CHD. Patient-specific 3D-printed heart models from cardiac CT or MRI images enhance surgeons' confidence in dealing with complex CHD cases, with successful outcomes achieved. 3D-printed personalized models serve as a complementary tool to standard imaging modalities for surgical planning of complex cardiac procedures, thus improving treatment outcomes of patients with complex CHD. As an emerging technology in cardiovascular disease, 3D-printed models have been shown to play a role in other imaging areas such as the development of optimal CT scanning protocols in coronary artery disease and coronary stenting,,,,,,, and pulmonary embolism., These early reports present promise of using 3D-printed realistic models in different cardiovascular disease domain, although more evidence is needed before 3D printing can be incorporated into routine clinical practice.
| References|| |
Zanetti EM, Aldieri A, Terzini M, Cali M, Franceschini G, Bignardi C. Additive manufacturing custom load-bearing implantable devices. Aust Med J 2017;10:694-700.
Giannopoulos AA, Steigner ML, George E, Barile M, Hunsaker AR, Rybicki FJ, et al.
Cardiothoracic applications of 3-dimensional printing. J Thorac Imaging 2016;31:253-72.
Zanetti EM, Bignardi C. Mock-up in hip arthroplasty pre-operative planning. Acta Bioeng Biomech 2013;15:123-8.
Speranza D, Citro D, Padula F, Motyl B, Marcolin F, Calì M, et al.
Additive manufacturing techniques for the reconstruction of 3D fetal faces. Appl Bionics Biomech 2017;2017:9701762.
Sun Z, Liu D. A systematic review of clinical value of three-dimensional printing in renal disease. Quant Imaging Med Surg 2018;8:311-25.
Perica ER, Sun Z. A systematic review of three-dimensional printing in liver disease. J Digit Imaging 2018;31:692-701.
Perica E, Sun Z. Patient-specific three-dimensional printing for pre-surgical planning in hepatocellular carcinoma treatment. Quant Imaging Med Surg 2017;7:668-77.
Lau I, Squelch A, Wan Y, Wong A, Ducke W, Sun Z. Patient-specific 3D printed model in delineating brain glioma and surrounding structures in a paediatric patient. Digit Med 2017;3:86-92. [Full text]
Aldosari S, Squelch A, Sun Z. Patient-specific 3D printed pulmonary artery model: A preliminary study. Digit Med 2017;3:170-7. [Full text]
Sun Z, Lee SY. A systematic review of 3-D printing in cardiovascular and cerebrovascular diseases. Anatol J Cardiol 2017;17:423-35.
Sun Z, Squelch A. Patient-specific 3D printed models of aortic aneurysm and aortic dissection. J Med Imaging Health Inf 2017;7:886-9.
Lau IW, Liu D, Xu L, Fan Z, Sun Z. Clinical value of patient-specific three-dimensional printing of congenital heart disease: Quantitative and qualitative assessments. PLoS One 2018;13:e0194333.
Valverde I, Gomez-Ciriza G, Hussain T, Suarez-Mejias C, Velasco-Forte MN, Byrne N, et al.
Three-dimensional printed models for surgical planning of complex congenital heart defects: An international multicentre study. Eur J Cardiothorac Surg 2017;52:1139-48.
Ryan J, Plasencia J, Richardson R, Velez D, Nigro JJ, Pophal S, et al
. 3D printing for congenital heart disease: A single site's initial three-year experience. 3D Print Med 2018;4:10.
Sun Z, Lau I, Wong YH, Yeong CH. Personalized three-dimensional printed models in congenital heart disease. J Clin Med 2019;8:E522.
Lau I, Sun Z. Three-dimensional printing in congenital heart disease: A systematic review. J Med Radiat Sci 2018;65:226-36.
Lau IW, Sun Z. Dimensional accuracy and clinical value of 3D printed models in congenital heart disease: A systematic review and meta-analysis. J Clin Med 2019;8:E1483.
Zhao L, Zhou S, Fan T, Li B, Liang W, Dong H, et al.
Three-dimensional printing enhances preparation for repair of double outlet right ventricular surgery. J Card Surg 2018;33:24-7.
Vettukattil JJ, Mohammad Nijres B, Gosnell JM, Samuel BP, Haw MP. Three-dimensional printing for surgical planning in complex congenital heart disease. J Card Surg 2019;34:1363-9.
White SC, Sedler J, Jones TW, Seckeler M. Utility of three-dimensional models in resident education on simple and complex intracardiac congenital heart defects. Congenit Heart Dis 2018;13:1045-9.
Loke YH, Harahsheh AS, Krieger A, Olivieri LJ. Usage of 3D models of tetralogy of fallot for medical education: Impact on learning congenital heart disease. BMC Med Educ 2017;17:54.
Lim KH, Loo ZY, Goldie SJ, Adams JW, McMenamin PG. Use of 3D printed models in medical education: A randomized control trial comparing 3D prints versus cadaveric materials for learning external cardiac anatomy. Anat Sci Educ 2016;9:213-21.
Sun Z, Ng CK, Squelch A. Synchrotron radiation computed tomography assessment of calcified plaques and coronary stenosis with different slice thicknesses and beam energies on 3D printed coronary models. Quant Imaging Med Surg 2019;9:6-22.
Sun Z. Personalized three-dimensional printed coronary artery models for accurate assessment of coronary stenosis using high resolution imaging. Aust Med J 2019;12:105-9.
Abdullah KA, McEntee MF, Reed W, Kench PL. Development of an organ-specific insert phantom generated using a 3D printer for investigations of cardiac computed tomography protocols. J Med Radiat Sci 2018;65:175-83.
Sun Z, Jansen S. Personalized 3D printed coronary models in coronary stenting. Quant Imaging Med Surg 2019;9:1356-67.
Sun Z. 3D printed coronary models offer new opportunities for developing optimal coronary CT angiography protocols in imaging coronary stents. Quant Imaging Med Surg 2019;9:1350-5.
Aroney N, Lau K, Daniele L, Burstow D, Walters D. Three-dimensional printing: To guide management of a right coronary artery to left ventricular fistula. Eur Heart J Cardiovasc Imaging 2018;19:268.
Velasco Forte MN, Byrne N, Valverde Perez I, Bell A, Gómez-Ciriza G, Krasemann T, et al
. 3D printed models in patients with coronary artery fistulae: Anatomical assessment and interventional planning. EuroIntervention 2017;13:e1080-e1083.
Aldosari S, Jansen S, Sun Z. Optimization of computed tomography pulmonary angiography protocols using 3D printed model with simulation of pulmonary embolism. Quant Imaging Med Surg 2019;9:53-62.
Aldosari S, Jansen S, Sun Z. Patient-specific 3D printed pulmonary artery model with simulation of peripheral pulmonary embolism for developing optimal computed tomography pulmonary angiography protocols. Quant Imaging Med Surg 2019;9:75-85.
[Figure 1], [Figure 2]