Research Assessment #4

Topic: Pediatric Cardiology

Date: October 12, 2018
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Analysis:

3D printing has been a topic of great interest and discussion for the past few
years as people realized the potential for application. It can be used in the fields of
manufacturing, businesses, industry and even in the field of medicine. Specifically,
3D printing has applications pertaining to the field of Pediatric Cardiology. 3D
printing can be used to create physical models of the heart of the patient which
allow the patient to gain a better understanding of their condition and how the
procedure they will go through will affect their heart. In addition, it allows for a
better understanding of the complex anatomy of a specific child’s heart for
physicians and students as the intricacies may not be easily represented in 2D
imaging such as CT and MR scans. Procedures may also be done more efficiently and
done in a shorter period of time as physical models would allow the surgeons to
grasp an understanding of what procedure would be the most effective for that
specific child (or adult with congenital heart disease). Although 3D printing in
Pediatric Cardiology is still in development and has a few cons, which include the
fact that they might not translate the information from 2D imaging accurately which
could lead to complications and the lack of materials to accurately represent the
function of the heart, it has the potential to greatly improve the understanding of
specific heart functions by the patient,
physician, and even medical students.
Technology in the medical field is evolving and flourishing to incorporate not
only increased efficiency in procedures, but also patient care. In the last article that I
analyzed, it discussed a recent venture by UC Davis Medical Center to implement
telemedicine to provide their patient families the benefit of being able to monitor
their child. While UC Davis Medical Center focuses more on patient care, 3D printing
allows for improvements on both aspects discussed, efficiency in patient care and
procedures.
This article really stood out to me as 3D printing wasn’t a method that I
thought could be implemented in the field of pediatric cardiology. The main point
that interested me was that each model was created to mimic the complexities of
the patient’s heart as closely as possible. It fascinates me how technology is being
used to make the process of communication with the patient more efficient and how
it’s being used to figure out the best solution tailored to each individual. Although
the process of making a model is costly and not time efficient, advancements in
materials that are cheaper and a more time efficient 3D printer would allow for
quicker medical procedures that have a more rapid recovery time. As an aspiring
pediatric cardiologist, knowing about the potential advancements in my field is very
important as this will be something I may be involved in with my career in the future.
I wish to research more into this topic and find other applications for 3D printing and
other technology in the field of pediatric cardiology.

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MLA Citation:

White, Shelby, and Michael D Seckeler. “3D Printing in Congenital Heart Disease:
How It Can Change Management Today and Tomorrow.” American College of
Cardiology, American College of Cardiology, 13 Sept. 2018, www.acc.org/latest-
in- cardiology/articles/2018/09/13/08/15/3d-printing-in-congenital-heart-
disease.

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(see next page for annotations)

Article Annotations:

3D Printing in Congenital
Heart Disease: How it Can
Change Management Today
and Tomorrow
Sep 13, 2018 | Shelby White, MD; Michael D. Seckeler, MD, FACC

Expert Analysis
Three-dimensional (3D) printing has evolved significantly since it was first
developed in the 1980s, with improvements in computing power and the
development of consumer 3D printers leading to more widespread use.
There has been an explosion in the use of 3D printing technology in
medicine. We present a brief overview of 3D printing technology and a
review of the current and future uses in the field of congenital heart
disease (CHD).

3D Printing Process

The typical process for generating a 3D printed model is fairly standard.

Using a 3D imaging dataset, typically from CT or MR data(1), the areas of
interest for printing are highlighted, a process called segmentation. While
there are some software programs available that can do this in a semi-
automated fashion, it is still mostly done manually(2). Once a segmented
model is generated, it needs to be cleaned to fix any errors made during
the segmentation process and to ensure that the model is actually
capable of being physically printed. The cleaned model is then sent to the
3D printer for printing; depending on the size and complexity of the
model, this can take anywhere from 1 to 24 hours(3) or more. There are
several different printer technologies available, included fused deposition
modelling, stereolithography and selective laser sintering, and there is a
wide range in the costs for the printers and materials and various
advantages and disadvantages for each.

Current Uses

3D printed models have been shown to be useful in facilitating

communication between physicians and patients as well as enhancing
medical education(4) for a variety of learners. The use of patient-specific
3D models(5) during consultation with adolescent CHD patients improved
their understanding of their condition(6) and may improve follow-up
during the transition from adolescence to adulthood(7).1 Models have
been used as an adjunct to didactic teaching about CHD for nurses,
medical students and resident physicians. Most studies have relied on
subjective data to identify an improvement in learner understanding and
confidence.2-6 Objective data in the form of pre- and post-lecture board-
style tests suggest that 3D models were a useful addition to lectures on
vascular rings(8).7

There have been an increasing number of studies showing the utility of 3D

printed models in clinical decision making and interventional
planning(9).8-12 CHD(10) is often associated with complex and unique
spatial relationships that can be difficult to grasp from 2D imaging, such
as CT, MRI or echocardiography(11). Double outlet right ventricle is a
common lesion for 3D modeling due to the complex geometry between
the ventricular septal defect (VSD) and the outflow tracts(12) which can
impact the ability to perform a biventricular repair. 3D models have been
used to understand the relationship between the VSD and the left
ventricular outflow tract for baffling and have been shown to be
associated with shorter surgical time(13), presumably as a result of better
preoperative understanding of the anatomy.8,12,13Interventional
catheterization procedures have also been facilitated by 3D models,
including atrial septal device closure in the setting of septal rim
deficiency, angioplasty of a pulmonary venous baffle in a patient with the
Mustard repair of transposition of the great arteries and device closure of
a mitral valve leaflet perforation due to bacterial endocarditis.10,14,15 These
procedures were simulated using 3D models, allowing practice of
complicated procedures and ensuring proper device selection before
attempting intervention(14).

Adults with CHD often have complex post-operative anatomy as well as

multiple prior surgeries that make re-intervention more challenging and
higher risk(15). Many are also at risk for developing heart failure(16) and
could benefit from mechanical cardiac support or heart transplantation,
but their anatomy and risk factors may preclude these. 3D printed models
can help identify the best approach for implanting mechanical support
devices as well as making decisions regarding appropriate donor(17)
harvesting for transplantation.16,17 This pre-procedural information may
have the added benefit of shorter surgical times as well.16

Novel Techniques

Currently, most 3D printed models are generated from single imaging

datasets (CT or MR). Newer techniques, described as "hybrid" 3D printing,
allow users to integrate imaging data from CT, MR and 3D
echocardiography(18) to maximize the benefits from each modality to
optimize the clinical data obtained from the models.18 This technique may
allow for generation of more accurate models for surgical planning,
particularly surgical valve interventions, but is still quite complicated and
time-consuming. There has also been early work utilizing datasets from
newer imaging modalities, such as rotational angiography during cardiac
catheterization, which appears promising as another source of accurate
imaging data for model generation.19 Work has also been done to try to
develop more lifelike 3D printed models for simulation by incorporating
multiple materials into one model, such as soft, rubbery material for
vessels or valves and harder materials to simulate calcifications(19).20

An important tool that has been developed is the National Institutes of

Health's 3D Heart Library (https://3dprint.nih.gov/collections/heart-
library), an online, free access library of digital 3D models that can be
downloaded and printed.21 The digital models are generated from MRI
data from actual patients and submitted by participating institutions. This
work is important for standardizing imaging, segmentation and model
generation techniques to ensure consistent accuracy(20), which will be
particularly important as 3D printed models become incorporated into
routine clinical care.

Current Limitations

There are significant technological limitations that need to be overcome

for the field to continue to advance. Several authors have noted that
currently there is no consistent, systematic method for segmentation of
imaging data to generate digital models(21) for
printing.22,23 Segmentation is a complex, time consuming process(22)
without a good semi- or fully automated option. In addition, each step of
segmentation and model preparation introduces potential for errors or
inaccuracies that could lead to incorrect surgical planning or novel device
development(23).20,24 Development of semi-automated cardiac
segmentation protocols that can be used universally, regardless of the
source data, will be a major area for improving 3D printing
implementation to speed up the process(24) of virtual and physical model
generation. Machine learning has been identified as a potential tool to
overcome many of these issues.22,25 Other issues include a lack of
materials that simulate actual cardiac structures and an inability to easily
show the dynamic structural changes that occur throughout the cardiac
cycle(25).23 The ability to produce sterile models that could actually be
held and manipulated by surgeons during a procedure(26) could allow for
more direct interaction during procedures and potentially provide different
views to aid in the intervention.8 Other major impediments to adoption
that will also need to be overcome are high start-up and maintenance
costs and long print times(27).

The Future

Perhaps the most exciting future use of 3D printing in medicine is

bioprinting. Bioprinting of cellular material is a developing method for
creating patient specific tissue engineered implants(28). Tissue
engineering has existed for some time, but with 3D printing, more lifelike
scaffolds for cells to migrate onto can be created. Currently there is no
ideal printer, but industry has taken notice and is working to develop
better printers that can provide optimal resolution and speed with low
costs and high viability of the printed cells(29). There is also an increasing
amount of work trying to print cells directly into the structures of
interest.26 One group has developed a technique using a patient-specific
3D printed mandrel as a guide for creating a cell-free tissue graft that can
be surgically implanted. Within 6 months, the underlying scaffold can be
almost completely resorbed and replaced with natural tissue that
essentially behaves like the normal surrounding vessel(30).27 The
potential to develop vascular grafts that can become replaced with a
patient's own tissue is a "holy grail" of congenital heart surgery that could
markedly reduce the need for re-operations to account for somatic
growth(31). The same group has also begun work on using their cell-free
tissue graft technique to develop personalized Fontan conduits that can be
embedded with the patient's own stem cells during the surgical
procedure(32).28 4D bioprinting is the newest evolution in which printing
materials are designed to respond to specific stimuli (such as heat)to alter
their shape(33). This could be a method to allow for growth of implanted
structures, such as stents, or eventually bioprinted bones and organs.29

3D printing will play a major role in the future care of children and adults
with CHD. It can allow for the ultimate "precision medicine" by tailoring
implantable prostheses and interventional devices to the specific needs of
each patient's complex congenital cardiac anatomy(34). Future
improvements in the software and hardware and ease of model
generation will lead to further adoption and integration into routine clinical
care.

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(1) Using data from imaging scans (CT/MR) models can be made
(2) Manual input is required (still a developing process)
(3) Model completed within the day (time efficient but cost efficient?)
(4) Help educate patients, parents, students etc.
(5) Model made of each person’s heart so problems can be identified
(6) a physical representation helps demonstrate what procedure will be done and how
(7) aids transition between pediatric and adult cardiology treatments as the
heart develops with procedures
(8) 3D models help those studying vascular rings specifically more than other
concepts
(9) helps physicians make decisions on what procedures to do and how to
follow through with them
(10) congenital heart disease
(11) the heart of a child is complex and unique and 2D imaging can be difficult
to understand
(12) Common lesion that 3D model helps
(13) Shorter surgical time due to better understanding of anatomy
(14) atrial septal device closure, angioplasty of a pulmonary venous baffle, device
closure of a mitral valve leaflet perforation due to bacterial endocarditis
(simulated using 3D models)
(15) adults living with congenital heart disease are difficult to practice procedures
on as previous procedures can lead to complications
(16) Heart failure can be prevented
(17) 3D models help select appropriate donors
(18) allows for usage of different imaging data to create a "hybrid" image
(19) use of different materials to create more lifelike models for simulation
(20) digital models developed from actual MRI data and is used as reference
material for more accurate
(21) no consistency in developing data for models
(22) takes up too much time
(23) could potentially do more harm than good if models are created incorrectly
(24) potential future improvements to increase efficiency of the idea
(25) limitations of the 3D model
(26) creation of models that would allow physicians to manipulate them and try
procedures
(27) other limitations
(28) implants made specifically to mimic each individual patient
(29) improvements are being made on the devices to do bioprinting
(30) bio printed implants will be absorbed by natural tissue
(31) re-operations are decreased as implants normalize tissue function as they
are overcome by natural tissue
(32) stem cells allow for regrowth of tissue
(33) new venture into medical technology where implants react to stimuli
(34) each implant tailored to fit the specific needs of each patient's complex heart