Elsevier

Heart, Lung and Circulation

Volume 28, Issue 10, October 2019, Pages 1525-1534
Heart, Lung and Circulation

REVIEW
Cardiovascular Three-Dimensional Printing in Non-Congenital Percutaneous Interventions

https://doi.org/10.1016/j.hlc.2019.04.020Get rights and content

Three-dimensional (3D) printing technology is emerging as a potential new tool for the planning of medical interventions. In the last few years, increasing data have accumulated on its ability to guide interventional cardiology procedures, going beyond initial reports in congenital heart disease settings. In fact, there is compelling evidence on the advantages of a 3D-printed guided strategy for left atrial appendage closure, suggesting a high success rate with optimal device selection and lower radiation load. Furthermore, there is emerging experience in aortic root printing, which may improve the success rate and safety of transcatheter aortic valve replacement and may be of particular interest for targeting low-risk populations. Additionally, there are stimulating reports in mitral valve intervention, setting the tone for this new field in cardiovascular percutaneous intervention. In this clinically oriented paper, we will review current 3D printing use in interventional cardiology and we will address future directions, with a focus on procedural planning and medical simulation.

Introduction

Three dimensional (3D) printing is emerging as a new tool for the diagnosis of several diseases and planning of medical procedures [1]. This technique is used to transform digital objects into physical models, providing not only improved anatomical visualisation compared with 3D imaging, but also a tactile experience.

Its use in the medical field has been steadily rising, particularly in surgical practice and in translational research. In 2016, a systematic literature review on 3D printing in medical practice reported that 45.2% of papers were on orthopaedics. Cardiovascular medicine accounted only for 3.5% of publications at that time [2]. That initial experience mainly concerned complex congenital heart disease and 3D-printed models were regarded as valuable instruments to plan interventions [3].

However, there is increasing interest in using this technology for guiding non-congenital interventional cardiology procedures and, accordingly, the number of publications in structural intervention is rising. In this clinically oriented paper, we will review current 3D printing applications in non-congenital interventional cardiology and we will address future directions, with a focus on procedural planning and medical simulation.

Section snippets

Fundamentals of Three-Dimensional Printing in Cardiovascular Medicine

The 3D printing process comprises several steps (Figure 1) that begin with volumetric image acquisition. Computed tomography (CT), magnetic resonance imaging, or 3D echocardiography datasets are the most frequently used modalities [4]. However, a 3D angiography volume may be obtained from a rotational angiography acquisition or from software-based reconstruction of planar angiographic images. These later modalities offer the advantage of being obtained locally in the catheterisation laboratory.

Left Atrial Appendage Occlusion

Left atrial appendage (LAA) occlusion is the interventional cardiology field where 3D printing has been used most extensively. This is because of the complex and highly variable LAA anatomy and owing to the importance of accurately sizing the occluder device in order to avoid leaks and procedural complications. Device sizing is usually done using angiography, angio-CT, transoesophageal echocardiogram (TOE), or a combination of these latter techniques for a multimodality imaging approach.

Aortic Valve Intervention

Transcatheter aortic valve replacement (TAVR) is a cornerstone of structural intervention in modern cardiology centres. To achieve a successful result, it is key to characterise the aortic root anatomy and choose the best device (type and size) to avoid complications. In particular, perivalvular leakage (PVL) is more common than surgical replacement and is associated with increased mortality [17].

In this context, 3D models of the aortic root and valve can be printed in order to better

Other Structural Interventions

Percutaneous mitral valve intervention is challenging because it is difficult to predict how the device will interact with complex native anatomy and if it will actually reduce regurgitation. Therefore, 3D printing methodology might be a powerful aid to such complex procedures [27]. The first report of preprocedural 3D printing to test transcatheter mitral valve intervention was published in 2016 [28]. It was a case of a patient with severe mitral valve regurgitation and posterior leaflet

Coronary Intervention

Three-dimensional printing has been infrequently used for planning coronary intervention. However, there is a report of 3D-printed models of complex coronary artery fistulae in four patients, which improved anatomical visualisation and were useful in planning the intervention [35]. Interestingly, an Asian group optimised stent implantation guided by 3D printing, in order to prevent restenosis. Specifically, the authors built a digital coronary model based on angiography, and in addition to

Simulation

Three-dimensional model-based simulation may be used for training, individualising medicine, and patient empowerment. In fact, by using simulation in interventional cardiology, the traditional approach “see one, do one, teach one” can be replaced by proper training before engaging in patient management. The Accreditation Council for Graduate Medical Education mandates that cardiovascular fellowship training programs have some component of simulation as part of fellow training [39]. Also, the

Discussion

Three-dimensional printing is gaining relevance in cardiovascular medicine, parallel to the increasing number and complexity of percutaneous procedures. This technology, which was initially restricted to top-notch expert centres when dealing with rare and complex diseases, is now becoming more available and backed up by studies that provide evidence to tackle common, yet complex, percutaneous procedures. Now, there are compelling data on the utility of medical 3D printing to guide LAA closure,

Funding Sources

No funding was provided for the writing of this review.

Conflicts of Interest

Manuel de Oliveira-Santos, Eduardo de Oliveira-Santos and João Silva Marques are co-founders of a medical three-dimensional printing start-up.

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