Using 3D printing to treat complex structural heart disease.

3D printing is a powerful technology with the potential to significantly change the practice of medicine. In the field of structural heart disease, this rapidly evolving technology can make a powerful impact.

Limitations of two-dimensional imaging and added benefits of 3D printing

Current conventional cardiac imaging modalities such as echocardiography (EKG), cardiac computed tomography (CT) or magnetic resonance imaging (MRI) primarily utilize two-dimensional (2D) methods that require significant expertise and experience to interpret. In the field of pediatric or congenital cardiology, complex structural heart disease requires precise anatomical delineation before intervention.  Consider a heart no larger than a walnut with multiple levels of abnormal connections. Using standard methods of visualization, whether by echo, CT or MRI, the interpreter essentially “reconstructs” a three-dimensional (3D) image from multiple slices or sweeps through this complex heart. By and large, this method works well for the structurally normal heart or for “simple” lesions (1); however, the challenges of interpretation and potential for errors are compounded for heart lesions of moderate or great complexity (1). Three-dimensional methods of visualization such as 3D echo, volume or surface rendering give the added perception of depth, but they are fundamentally limited by 2D displays on which they are viewed. Thus, complex, three-dimensional spatial relationships, such as pathways between the atrio-ventricular (AV) inflows, ventricular septal defects (VSDs) and cardiac outflows are limited to visualization in 2D planes that require significant expertise and experience to interpret accurately. Similar limitations exist in cases of abnormal extra-cardiac vasculature, where exact relationships between vascular (artery, vein, etc.) and non-vascular structures (airways, esophagus, etc.) are important to know, but difficult to interpret for complex abnormalities.

In the current era of multi-disciplinary care, these limitations of 2D imaging are especially relevant. Consider the patient with complex cardiovascular defects receiving care at a modern medical center. In this environment, the care team for such a patient usually consists of multiple subspecialists, each bringing their own expertise and experiences to the table. Within this team, the understanding of complex structural heart disease varies, either because of experience level (e.g., trainee versus experienced faculty) or background (e.g., imager vs. surgeon vs. intensivist). While the multi-disciplinary team is critical for comprehensive care of patients, variations in background makes accurately communicating a complex diagnosis challenging, and there is a potential for miscommunication and subsequent medical errors.

In recent years, 3D printing has emerged as a breakthrough technology for treating that offers several improvements over the status quo including (2-5):

• Improved patient care outcomes
• Trainee education and technical skills
• Patients and caregiver counseling

Enhanced pre-surgical planning and patient care outcomes

3D printing produces a replica of the patient’s anatomy. In patients with complex congenital heart disease (CHD), this allows precise understanding of the patient’s anatomy and the resultant physiology. 3D printing in CHD has been used in recent years as an adjunct to conventional imaging methods for surgical planning (6,7). This technology solves some of the challenges of 2D imaging discussed in the prior section by enabling more informed decisions and precise pre-surgical planning. The models help dissipate some of the mystery surrounding complex anatomic malformation by allowing practitioners to hold, inspect and manipulate the replica, and facilitate in-depth discussions within members of the multidisciplinary team (8,9). Additionally, the models enable better discussions with the patient and caregivers regarding the diagnosis and therapeutic options, as discussed in the next section.

For surgical planning, 3D models enable detailed planning based on a physical model that can be held, manipulated in real 3D space, and scrutinized to plan various aspects of the surgery, including surgical approach, incision, cannulation technique, etc.

In addition, 3D models facilitate thinking through of alternate plans (Plan A, Plan B, etc) and “exit strategies” if/when intraoperative complications arise. This sort of precise pre-surgical planning may lead to shorter operative times and fewer operative complications. Shorter cardiopulmonary bypass time, circulatory arrest time and fewer residual lesions requiring re-intervention are desired outcomes of precise pre-surgical planning from 3D printed models. These improvements in the operating room may translate to quicker recovery and a shorter post-operative hospital stay. Cardiac 3D printing is a nascent field, and at this time there is limited data to prove these beneficial outcomes. However, utilization of this technology is growing, and, with time, the potential benefits of 3D printing may be proven may be proven in scientific studies. Until we have data from large outcomes studies, the intuitive nature of 3D printing and clinical demand from surgeons and interventionalists will spur on this practice at leading cardiac programs. As one cardiothoracic surgeon described: “Having a 3D printed model is like walking down a dark street with the lights turned on.”

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Trainee education

Today’s academic medical centers tend to provide the most cutting edge, advanced medical therapies. These are also teaching centers with trainees composing a vital part of the medical team. Interpreting and diagnosing complex pathology from conventional 2D imaging studies requires skill garnered from years of experience, and poses considerable challenges for trainees building up their experience as they progress towards independent practice. For imaging/non-interventional trainees, 3D models aid in the understanding of complex anatomy and augment current traditional methods of education. For trainees in surgical subspecialties, 3D printed models can serve as important tools for surgical simulation on which they can practice techniques and procedures before assisting with a live operation. Furthermore, electronic models on virtual reality or holographic displays can provide an immersive and interactive learning experience unlike any current non-3D technology can offer. At the moment, most of these are fledgling technologies, but with tremendous growth potential. Today’s generation of young physicians have grown up with technology, and adoption of 3D-based training modalities seems a natural evolution in medical education.

Patient and caregiver counseling

In addition to assisting medical teams provide enhanced care, 3D printing can be a very effective practice for patient and caregiver counseling. Imagine for a moment you are the parent of a child with a newly diagnosed, complex heart defect. The clinicians converge to explain the diagnosis and to offer therapeutic options. If the diagnosis comes as a surprise, you are faced with myriad emotions while grappling to understand the diagnosis itself. Even if the diagnosis was predicted in advance, perhaps via fetal echocardiography, the magnitude and complexity of the situation in real-time is overwhelming. At our center, we have found 3D models can help improve communication with the patient and patient’s family at this challenging time when integrated into our discussions with the family. The models provide a tangible reference for education and discussion of treatment options, with the goals of increasing a family’s understanding of the heart disease and therapeutic options. Anecdotally, we have received very positive feedback from families who have undergone counseling utilizing 3D models, and we have integrated this into our clinical practice.

Ideal cases for cardiovascular 3D printing

Cardiovascular 3D printing has wide-raging applications, and the clinical utilization essentially depends on the needs of the medical and surgical teams. As discussed, in complex structural heart disease, advanced 3D visualization of intracardiac structures can significantly add to surgical planning. Examples include patients with outflow abnormalities, such as double outlet right ventricle (DORV). In these cases a complex intracardiac baffle or arterial switch may be required to successfully execute a two-ventricular repair.

Extracardiac cases benefiting from 3D printing include patients with complex vascular lesions. One example is the entity of pulmonary atresia and multiple aorto-pulmonary collaterals. For these patients, precise visualization of these abnormal vessels and relationship with surrounding structures (airways, veins, etc.) can assist surgeons plan a unifocalization surgery to minimize complications and blood loss.

Adult patients with congenital heart disease (ACHD) facing surgery can derive the same benefits of precise planning as previously discussed. In addition, in this population who may have previously undergone multiple heart surgeries, 3D printing allows surgeons to minimize the risks associated with sternal re-entry by precisely planning out the extent of dissection and cannulation techniques. Finally, in ACHD patients, 3D printing yields highly precise anatomic diagnoses, a distinct advantage over standard echocardiography, given deteriorating acoustic windows over time.

Lessons learned from 3D printing at our institution

• 3D modeling can be a time and labor intensive process, thus appropriate case selection is key.
• Discussion of clinical priorities for the 3D model with the referring provider is vital. For example, delineation of intracardiac anatomy and potential for two-ventricle repair in a patient with double outlet right ventricle.
• Quality control is paramount. Thus, active involvement of a physician with expertise in cardiac imaging is essential during key steps of 3D modeling (segmentation, design, printing, etc).
• Close communication with the 3D engineer, i.e., the individual performing segmentation, design, etc., is key.
• There are many different options for 3D models: rigid, multi-color, single-color, semi-rigid, etc. The type of 3D model used will be determined by the needs of the clinical team. Ideally, for teams taking care of complex patients, a printer capable of high-resolution prints in a variety of colors and material density provides the most flexibility for 3D printing.

From a practical standpoint, the acquisition of a high-quality 3D printer and software needed for medical-grade 3D printing is a costly proposition. Teaming up of subspecialties that utilize 3D printing across the institution may allow cost-sharing to enable the start-up of a 3D printing program. In academic centers that are university-affiliated, partnering with Engineering or Biomedical Sciences may also offer opportunities to start or grow a 3D printing program.

3D printing is a growing and essential technology in a modern medical program, which works in order to achieve the best clinical outcomes, provide cutting-edge education to trainees, and deliver the highest level care to patients and their families. At present, this advanced capability is a “key differentiator” that distinguishes a medical program. However, with broader implementation of 3D printing in medical practice, hospitals may find the lack of a 3D program is a deficiency in the near future. In conclusion, it may be inaccurate to consider 3D printing the “wave of the future” at this time. The technology has matured for precise applications in complex medical care, thus 3D printing has already arrived and will likely expand as a staple of modern medicine.

References

1. Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008 Dec 2;118(23):e714–e833.


2. Costello JP, Olivieri LJ, Su L, Krieger A, Alfares F, Thabit O, et al. Incorporating Three‐dimensional Printing into a Simulation‐based Congenital Heart Disease and Critical Care Training Curriculum for Resident Physicians. Congenital Heart Disease. 2015 Mar 1;10(2):185–90.


3. Farooqi KM, Uppu SC, Nguyen K, Srivastava S, Ko HH, Choueiter N, et al. Application of Virtual Three-Dimensional Models for Simultaneous Visualization of Intracardiac Anatomic Relationships in Double Outlet Right Ventricle. Pediatr Cardiol. Springer US; 2015 Aug 9;37(1):90–8.


4. Ryan JR, Moe TG, Richardson R, Frakes DH, Nigro JJ, Pophal S. A novel approach to neonatal management of tetralogy of Fallot, with pulmonary atresia, and multiple aortopulmonary collaterals. …. 2015 Jan 1;8(1):103–4.


5. Hu A, Wilson T, Ladak H, Haase P, Fung K. Three-dimensional Educational Computer Model of the Larynx: Voicing a New Direction. Arch Otolaryngol Head Neck Surg. American Medical Association; 2009 Jul 1;135(7):677–81.


6. Biglino G, Capelli C, Wray J, Schievano S, Leaver LK, Khambadkone S, et al. 3D-manufactured patient-specific models of congenital heart defects for communication in clinical practice: feasibility and acceptability. BMJ Open. 2015 Apr 1;5(4):e007165–5.


7. Anwar S, Singh GK, Varughese J, Nguyen H, Billadello JJ, Sheybani EF, et al. 3D Printing in Complex Congenital Heart Disease: Across a Spectrum of Age, Pathology, and Imaging Techniques. JACC: Cardiovascular Imaging. 2016 Jul 14.


8. Jacobs S, Grunert R, Mohr FW, Falk V. 3D-Imaging of cardiac structures using 3D heart models for planning in heart surgery: a preliminary study. Interactive CardioVascular and Thoracic Surgery. Oxford University Press;2008 Feb;7(1):6–9.


9. Gosnell J, Pietila T, Samuel BP, Kurup HKN, Haw MP, Vettukattil JJ. Integration of Computed Tomography and Three-Dimensional Echocardiography for Hybrid Three-Dimensional Printing in Congenital Heart Disease. Journal of Digital Imaging. 2016 Apr 12.