3D Printing is a Transformative Technology in Congenital Heart Disease

Abstract

Survival in congenital heart disease has steadily improved since 1938, when Dr. Robert Gross successfully ligated for the first time a patent ductus arteriosus in a 7-year-old child. To continue the gains made over the past 80 years, transformative changes with broad impact are needed in management of congenital heart disease. Three-dimensional printing is an emerging technology that is fundamentally affecting patient care, research, trainee education, and interactions among medical teams, patients, and caregivers. This paper first reviews key clinical cases where the technology has affected patient care. It then discusses 3-dimensional printing in trainee education. Thereafter, the role of this technology in communication with multidisciplinary teams, patients, and caregivers is described. Finally, the paper reviews translational technologies on the horizon that promise to take this nascent field even further.

Keywords: 3D printing; 3D, three-dimensional; ACHD, adults with congenital heart disease; APC, aortopulmonary collaterals; ASD, atrial septal defect; CHD, congenital heart disease; CT, computed tomography; DORV, double outlet right ventricle; MAPCAs, multiple aortopulmonary collaterals; MRI, magnetic resonance imaging; OR, operating room; VSD, ventricular septal defect; cardiac imaging; cardiothoracic surgery; congenital heart disease; simulation.

Graphical abstract

Central Illustration

Applications of 3D Printing in Congenital Heart Disease

Figure 1

Application of 3D Printing in Medicine Most of these applications pertain to cardiology, except for wearable devices, for which the authors did not find any cardiac-specific published reports.

Figure 2

3D Printing Technologies ABS = acrylonitrile butadiene styrene; CJP = color jet printing; Co = cobalt; Cr = chromium; DLP = direct light processing; FDM = fused deposition modeling; FFF = fused filament fabrication; HIPS = high impact polystyrene; Ni = nickel; PLA = polylactic acid; PVA = polyvinyl alcohol; SLA = stereolithography apparatus; SLM = selective laser melting; SLS = selective laser sintering; Ti = titanium; TPE = thermoplastic elastomer; TPU = thermoplastic urethane.

Figure 3

Blood Pool Cardiac 3D Model Source images on the left show the segmented blood pool signal. The model is shown on the right.

Figure 4

Hollow Cardiac 3D Model Showing Intracardiac Anatomy

Figure 5

Models for Surgical Planning (A) Flexible hollow model printed intact with corresponding rigid multicolor model. (B) The “surgeon’s view” through a right atriotomy. IVC = inferior vena cava; RA = right atrium.

Figure 6

3D Model of Double-Outlet RV Showing Relationships Among Ventricles, VSD, and Outflows The dashed line indicates the potential ventricular septal defect (VSD) baffle pathway to achieve a 2-ventricle repair. Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; SVC = superior vena cava; other abbreviations as in Figure 5.

Figure 7

Simulated Surgery for Complex Total Cavopulmonary Connection Planning Using Flexible, Intact-Heart Model See Supplemental Video 1. LPA = left pulmonary artery; RPA = right pulmonary artery; RSVC = right superior vena cava; other abbreviations as in Figures 5 and 6.

Supplemental Video 1

Figure 8

Staged Repair of Tetralogy of Fallot, Pulmonary Atresia, and MAPCAs (A) Pre-operative anatomy. (B) Unifocalization of right-sided major aortopulmonary collateral arteries (MAPCAs) and small right pulmonary artery (PA)–to–right modified Blalock-Taussig-Thomas shunt. (C) Use of 3D model in the operating room for procedural guidance. (D) Unifocalization of left-sided major aortopulmonary collateral arteries–to–left modified Blalock-Taussig-Thomas shunt. (E) Right ventricular (RV)–to–pulmonary artery conduit placement (green) to unifocalized major aortopulmonary collateral arteries and takedown of bilateral modified Blalock-Taussig-Thomas shunts. APC = aortopulmonary collateral; LSCA = left subclavian artery; PTFE = polytetrafluoroethylene; SVC = superior vena cava.

Figure 9

Heterotaxy, Unbalanced Atrioventricular Canal, Ventricular Inversion, Modified Fontan (A) 3D model showing a left ventricle (LV)–to–left superior vena cava (LSVC) conduit and left-sided Glenn procedure that complicates transplantation of a normal donor heart. (B) Intracardiac anatomy. (C) Intraoperative findings: explanted heart and a left ventricle–to–left superior vena cava conduit, showing accuracy of the 3D model. ASD = atrial septal defect; other abbreviations as in Figures 6 and 7.

Figure 10

Airway Abnormalities in Congenital Heart Disease (A) Vascular ring with posterior compression of trachea by a circumflex transverse arch coursing behind the aorta. (B) Severe branch pulmonary artery dilation in tetralogy of Fallot with absent pulmonary valve with compression and malacia of bilateral mainstem bronchi. Abbreviations as in Figure 7.

Figure 11

Bioresorbable Airway Splint Manufactured From Polycaprolactone With a Bellowed Design to Promote Expansion and Growth Over Time

Figure 12

3D Printed Model in a Case of TOF With Borderline Large PA Measurements Image on the left shows a stent within main pulmonary artery (MPA). Image on the right is an angiogram taken after successful transcatheter implantation of pulmonary valve. PA = pulmonary artery; TOF = tetralogy of Fallot.

Figure 13

3D Models of Adults With Congenital Heart Disease (A) A 31-year-old patient with dextrocardia, a double-outlet right ventricle (DORV), and a Fontan procedure. (B) A 19-year-old patient with a bicuspid aortic valve (not shown) and a severely dilated aortic root and ascending aorta. (C) A 40-year-old patient with a double-outlet right ventricle, 2 VSDs, and classic Glenn and modified Mustard procedures (conduit from inferior vena cava [IVC] to left atrium [LA], in green). (D) A 45-year-old patient with a left dominant unbalanced atrioventricular canal, a double-outlet right ventricle, and right ventricular outflow tract obstruction. Abbreviations as in Figures 5, 6, 7, and 8.

Figure 14

Patient and Model Doppler Comparisons Doppler profile of a patient’s echocardiogram on the left, compared with the Doppler image from the 3D printed model on the right. Arrows point towards the aortic valve from the patient's echocardiogram (left) and model (right).

Figure 15

Simulated Arterial Switch Operation From a Hands-on Surgical Training Course for Cardiothoracic Surgeons Reproduced with permission from Yoo et al. . See Supplemental Video 2. LCA = left coronary artery; other abbreviations as in Figures 5 and 6.

Supplemental Video 2