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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 4  |  Page : 129-132

Personalized three-dimensional printed models assist presurgical planning and treatment of complex congenital heart disease

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 Submission21-Oct-2019
Date of Decision28-Oct-2019
Date of Acceptance12-Nov-2019
Date of Web Publication13-Apr-2020

Correspondence Address:
Zhonghua Sun
Discipline of Medical Radiation Sciences, School of Molecular and Life Sciences, Curtin University, Perth
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_23_19

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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 2023 Mar 29];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.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] 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.[8],[9],[10],[11],[12],[13] 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.[12],[13],[14],[15],[16]

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.[17] 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.[13],[14],[18] A recent study by Vettukattil et al. provided further evidence of how 3D-printed models improved surgical treatment in patients with complex CHD.[19] 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.[20]

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.[15],[16],[17],[21],[22] Valverde et al., in their multicenter study, provided the convincing results of using 3D-printed models in treating patients with complex CHD.[13] 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.[19]

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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.[19]

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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.[16],[17] 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,[23],[24],[25],[26],[27],[28],[29] and pulmonary embolism.[30],[31] 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.

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  [Figure 1], [Figure 2]


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