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Sun, Z.;  Wee, C. 3D Printed Models in Cardiovascular Disease. Encyclopedia. Available online: https://encyclopedia.pub/entry/28036 (accessed on 19 May 2024).
Sun Z,  Wee C. 3D Printed Models in Cardiovascular Disease. Encyclopedia. Available at: https://encyclopedia.pub/entry/28036. Accessed May 19, 2024.
Sun, Zhonghua, Cleo Wee. "3D Printed Models in Cardiovascular Disease" Encyclopedia, https://encyclopedia.pub/entry/28036 (accessed May 19, 2024).
Sun, Z., & Wee, C. (2022, September 29). 3D Printed Models in Cardiovascular Disease. In Encyclopedia. https://encyclopedia.pub/entry/28036
Sun, Zhonghua and Cleo Wee. "3D Printed Models in Cardiovascular Disease." Encyclopedia. Web. 29 September, 2022.
3D Printed Models in Cardiovascular Disease
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This entry is adapted from the peer-reviewed paper 10.3390/mi13101575

Three-dimensional (3D) printed models are increasingly used in medical education, with promising results achieved when compared to traditional teaching methods. Studies have shown its educational value in two areas as assessed by medical students and clinicians (cardiothoracic surgeons, cardiologists, cardiac imaging specialists including radiologists and radiographers, residents or registrars, and clinical nurses).

3D printing visualization heart vascular disease

1. Education Value of Three-Dimensional (3D) Printed Models in Cardiovascular Disease

3D printed models are increasingly used in medical education, with promising results achieved when compared to traditional teaching methods. Studies have shown its educational value in two areas as assessed by medical students and clinicians (cardiothoracic surgeons, cardiologists, cardiac imaging specialists including radiologists and radiographers, residents or registrars, and clinical nurses) [1][2][3][4][5][6][7][8][9][10][11][12][13][14].

1.1. Medical Student Education

Several studies based on randomized controlled trials (RCTs) and cross-sectional or cohort studies have documented the educational value of 3D printed models in cardiovascular anatomy and pathology [1][2][3][4][5][6][15]. Most of these studies proved the significant improvements in students’ knowledge and understanding of both normal cardiac anatomy and pathology (mainly in congenital heart disease) with the use of 3D printed models over the current teaching methods such as using 2D or 3D diagrams, cadavers and educational lectures. Three-dimensional printed heart and vascular models were shown to increase students’ confidence in recognizing cardiac anatomical structures and congenital anomalies. One recent study investigated whether 3D printed heart models improved the immediate and long-term knowledge retention among medical students when compared to the current teaching methods [2]. Authors delivered an education workshop comprising 2D cardiac CT images and 3D digital models to both control and 3D printing groups (53 second- and third-year medical students), while the 3D printing group received 3D printed models as additional components. Four types of congenital heart disease (CHD) were presented to the medical students who completed an online quiz at the end of the session and another online quiz 6 weeks later. The results showed no significant improvements in both immediate knowledge and knowledge retention with the use of 3D printed CHD models, despite slightly higher scores obtained in the 3D printing group than in the control group.

1.2. Clinician Education

Due to the complexity and wide heterogeneity of CHD lesions, it is difficult to fully understand the complex 3D anatomy and pathology on a 2D flat screen, thus rendering 3D printed models a valuable tool for the education of clinicians or healthcare professionals. Most of the studies reported the educational value of using 3D printed CHD models in pediatric or medical residents [7][8][9][10][11], with some involving pediatric cardiologists [10]. There is consistent agreement among these studies that 3D printed models significantly increased the participants’ knowledge of cardiac anatomy and CHD pathology when compared to conventional education or imaging approaches. Significantly higher scores were achieved in the 3D printing groups than those in the control groups, and this is especially apparent when complex CHD was involved [11][14], and 3D printed models were rated as an excellent tool for anatomy teaching, as well as improving diagnostic rate assessed by both experts and students [14].
Interestingly, a recent study by Lau et al. compared 3D printing with virtual reality (VR) technologies in 4 selected CHD cases among 29 participants [7]. All participants received a 15-min session of 2D/3D visualizations plus 3D printed CHD models and VR. There was no significant difference between these two tools in medical education and preoperative planning of CHD. Thus, it is highlighted that the potential value of using VR in combination with 3D printing technology in medical education. In addition to VR, advanced innovative tools, including augmented reality (AR) and mixed reality (MR), have also been applied in medical education by providing immersive learning experiences that may enhance the teaching and learning of complex content such as cardiovascular anatomy and pathology [16][17][18][19]. Barteit et al. conducted a systematic review of VR, AR and MR in medical education through an analysis of 27 studies comprising 956 participants [20]. Medical students (59.9%) and residents represented (30.2%) most of the participants with AR and MR mainly implemented in surgery training (48%) and anatomy learning (15%). Herein, it is highlighted the effectiveness of using VR, AR or MR tools in teaching cardiac anatomy and pathology [18][19][20]. The use of 3D-printed physical models, along with these novel visualization tools, will further enhance medical education.
Two studies investigated the educational value of 3D printed models for cardiac nurses or nursing students. Tan et al., in their RCT, randomly allocated 132 nursing students of congenital heart surgery to the 3D printing or traditional groups to assess their knowledge and critical thinking of a real case of atrial septal defect [12]. Significant higher scores were found in the 3D printing group than those in the traditional group regarding students’ comprehensive thinking ability of cardiovascular anatomy and congenital heart disease. Biglino et al. showed that the 3D printed heart and CHD models enhanced cardiac nurses’ knowledge of understanding cardiac anatomy and pathology [13]. There was no significant difference regarding the usefulness of 3D printed models in understanding different cardiac defects.

2. Clinical Applications of 3D Printed Models in Cardiovascular Disease

Clinical applications of using 3D printed models in cardiovascular disease are manifested in four areas: assisting pre-surgical planning of complex cardiac surgery procedures, simulation of surgical or interventional radiology procedures for medical residents or trainees, improving doctor-to-patient communication and development of optimal CT scanning protocols for reduction of radiation dose. The following sections will review these applications based on the current research studies.

2.1. Pre-Surgical Planning of Complex Cardiac or Cardiovascular Procedures

Application of 3D printed models in pre-surgical planning of complex cardiac or cardiovascular procedures represents the most common applications, and this is shown in a recent review article with nearly 50% of the applications on the assessment of the clinical value of 3D printed models in pre-surgical planning or simulation of cardiovascular procedures [21][22]. The multi-center study by Valverde et al. is a well-recognized report involving ten international centers with the inclusion of 40 complex CHD cases. In nearly half of the cases (47.5%), a surgical decision was changed with the use of 3D printed heart models, while in 28 cases conventionally considered for surgery, the surgical approach was modified in 15 cases (53.6%) after evaluating the 3D printed models [23].
Three single-center studies documented their three years and eight years of experience in using 3D printed models in CHD surgeries with the creation of more than 100 models [24][25][26]. Gomez-Ciriza and colleagues developed 138 affordable 3D printed models (an average cost per model is EUR85.7) and presented similar findings as Valverde et al., with 47.5% of surgical planning modified with the use of 3D printed models when compared to the original surgical plan. Further, these 3D printed models were scored useful for communicating with patients and parents when assessed by cardiac surgeons and pediatric cardiologists [24]. Ryan et al. reported their three years of experience with the generation of 164 models for a range of purposes [25]. When compared to the standard of care pre-procedural planning, 3D printed models reduced the operating length of time, 30-day mortality and readmission rate, although this did not reach statistical significance. Ghosh et al. reviewed the growth and development of using more than 100 3D printed models in their practice over a period of 3 years, with 96 of the models used for operative planning of CHD cases. Their experience shows that 3D printing can be incorporated into the pre-procedural planning of CHD in a pediatric clinical center [26].
Other studies based on case series or case reports (<30 cases) from a single-center experience showed consistent findings that 3D printed models assisted pre-surgical planning and simulation of CHD and cardiomyopathy. Russo et al. applied 3D printed models of aortic stenosis to simulate transcatheter aortic valve replacement (TAVR) for predicting the risk of developing coronary artery obstruction or complications. The simulation results of 3D printed models correlated well with clinical outcomes and thus can be used to plan TAVR procedures for reducing potential risks or complications [27].
Lau et al. further compared 3D printed models with VR in the clinical value of these two tools in preoperative planning and education of CHD [7]. Interestingly, both VR and 3D printed models are useful for understanding complex CHD conditions and preoperative planning when compared with the standard 2D or 3D visualizations, although VR scored higher than 3D printed models with no significant difference. Similar findings were reported by Chen et al. with VR and MR using Hololens enhanced understanding of intracardiac anatomy when compared to 3D printed models [28]. This could highlight the potential value of using VR/MR in pre-surgical planning of cardiovascular disease when a 3D printing facility is not available or using a combination of both methods [20].

2.2. Simulation of Surgical or Interventional Procedures

One of the common applications of 3D printing lies in guiding left atrial appendage occluder device selection to improve treatment outcomes and reduce potential complications associated with LAA occluder procedures. RCT, case-control and cross-sectional studies have shown the significant advantages of 3D printing guided procedures over traditional methods based on imaging (CT, echocardiography or intraoperative angiography), with key findings, including: good agreement between 3D printed model-based sizes and finally implanted occluder device sizes; reduced procedure time with no major adverse events or mortality and reduce radiation exposure to patients when compared to the control group without having 3D printed models [29][30][31][32]. Further, it seems the clinical value of 3D printed models depends on the type of occluder devices, as the correlation between 3D printed models and inserted device size was different for different occluders [33]. This may need to draw attention to clinicians when choosing different devices in planning the treatment of LAA.
Another common application of 3D printing is to simulate cardiac or cardiovascular procedures, in particular, interventional cardiology or radiology procedures, for training surgeons or trainees to perform complex or challenging procedures. The use of personalized 3D printed vascular models aims to increase the confidence and surgical skills of surgeons prior to operating on real patients [34][35][36][37][38][39][40]. Endovascular aneurysm repair (EVAR) is a widely used, less invasive procedure for treating aortic dissection and aneurysm, and the use of 3D printed models in simulating EVAR procedures has significantly reduced fluoroscopy time, procedure time, contrast medium and cannulation time when compared to the control group using standard training approach [35][38][41][42][43][44]. Similar findings are also reported by a recent study on the use of 3D printed CHD models for a hands-on training program to simulate interventional cardiology procedures [40].
Printing materials have an impact on the user’s performance when performing a simulation of interventional procedures as 3D models printed with soft and elastic materials allow the user to acquire a similar tactile experience to human vascular tissue, and this is especially important for structures like vessels and cardiac valves as highlighted in some studies [39][40]. Current developments in 3D printing technologies and printing materials have enabled achieving this goal with the selection of appropriate materials to replicate human cardiovascular tissue properties [45][46]. Evidence strongly recommends that 3D printed vascular models serve as a valuable tool for simulating and rehearsing cardiac or interventional radiology procedures.
Rynio et al., in their recent study, tested the effect of sterilization on 3D printed aortic templates, which are used in aortic stent grafting. They chose a complex case of aortic arch dissection and printed 11 models with use of six common materials. The sterilization was performed under three different methods and temperatures to determine the change of 3D printed model geometry and dimensions.

2.3. Enhancement of Doctor-to-Patient Communication

The role of using 3D printed models in enhancing doctor-patient communication has been reported in the literature, although only a limited number of studies are available, according to a recent scoping review. Traynor et al. conducted a comprehensive review of the current literature and identified 19 studies on the use of 3D printing in patient communication [47]. Of these studies, seven studies were related to cardiology and cardiovascular surgery [48][49][50][51][52][53][54], of which four studies were reported from the same research group [49][50][51][52]. Biglino and colleagues investigated the impact of 3D printed CHD models on communication from the perspectives of different stakeholders, including clinicians (cardiologists), patients and the parents of patients. Results of these studies presented consistent findings that 3D printed models facilitated communication with colleagues, patients and parents, with a significant improvement in patients′ and parents’ knowledge or understanding of the disease condition, or satisfaction [51]. The other three studies also supported the improvement between doctor-patient or between clinicians’ communication with the use of 3D printed models heart models [48][53][54]. More research needs to be done on patient engagement in decision-making through understanding their disease conditions by use of 3D printing.

2.4. Development of Optimal CT Scanning Protocols

Application of 3D printed models in developing optimal CT scanning protocols is a new research direction with only a few studies available in the literature, but with promising results achieved. Cardiac CT is a widely used modality for diagnostic assessment of cardiovascular disease, most used in coronary artery disease, aortic aneurysm or dissection and pulmonary embolism [55][56][57]. The main concern of cardiac CT is a high radiation dose; hence, the use of appropriate CT scanning protocols is clinically important for the reduction of patient radiation exposure without compromising image quality. Despite commercially available anthropomorphic human phantoms for dose reduction and image quality experiments, they are not only expensive but do not represent an individual patient’s situation due to the use of average adult or pediatric body sizes. The 3D-printed personalized models based on CT images overcome these limitations by producing individualized heart or cardiovascular models for studying CT protocols.
Several studies have explored the feasibility of developing 3D printed heart and vascular models for CT dose optimization [58][59][60][61][62][63][64][65][66][67]. Abdullah et al. developed an organ-specific cardiac insert phantom for the investigation of cardiac CT scanning protocols. Although it does represent the novelty of the study design with the simulation of surrounding cardiac structures as well as contrast medium during cardiac CT scan, the study lacks personalized 3D printed anatomical structures [58]. Morup et al. tested four different materials (gelatin mixtures, pig hearts and EcoflexTM silicone) with the aim of determining the appropriate one to simulate human heart and vascular tissue properties. Their results showed that the contrast-filled Ecoflex TM silicone had a mean CT attenuation of 318 Hounsfield Units (HUs) which is close to the contrast enhancement CT attenuation in real patients, serving as a cost-effective model for CT protocol optimization [59].
Personalized coronary artery models and aorta models using CT images for optimizing CT protocols and visualization of coronary calcified plaques and stenting [60][61][62][63] have been developed. Calcified plaques were created using a mixture of silicone, ethiodized oil and carbonate to simulate calcification in the coronary arteries. The combination of silicone and 32.8% calcium carbonate was found to produce CT attenuation of 800 HU, representing extensive calcification; thus, it is suitable for studying CT protocols for assessing calcified coronary plaques [60].
Further, 3D printed models of type B aortic dissection were developed using CT datasets to replicate true lumen, false lumen, aortic aneurysm, and insertion of the aortic stent graft to simulate EVAR [45]. CT scans were conducted to investigate the optimal aortic CT angiography (CTA) protocols in the follow-up of patients with aortic dissection following EVAR treatment. Low kilovoltage peak (80 kVp) and high pitch (2.0) can be suggested as the optimal CT protocol with a reduction of more than 20% radiation dose without affecting image quality as assessed quantitatively and qualitatively [45][65]. Since aorta CTA is the preferred imaging modality for both diagnosis of aortic aneurysm/dissection and follow-up of EVAR patients due to consecutive CT scans at regular periods, low-dose CT protocol is of paramount importance to minimize radiation dose. Thus, the use of 3D printed personalized aorta models will have great potential in the future to optimize current CT scanning protocols.
Another area of using a personalized 3D printed model lies in the simulation of pulmonary embolism with the model scanned using a range of CT pulmonary angiography protocols. Significant dose reduction by up to 80% was achieved with the use of low dose (70–80 kVp) and high pitch (3.2) with acceptable image quality when assessing pulmonary embolism, either in the main or side branches [66][67]. The main limitation of these studies is the lack of placing the 3D printed model in a realistic chest phantom with surrounding lungs, bones or cardiac structures. This needs to be addressed in future experiments.

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  51. Biglino, G.; Moharem-Elgamal, S.; Lee, M.; Tulloh, R.; Caputo, M. The perception of a three-dimensional-printed heart model from the perspective of different stakeholders: A complex case of truncus arteriosus. Front. Pediatr. 2017, 5, 209.
  52. Biglino, G.; Capelli, C.; Leaver, L.K.; Schievano, S.; Taylor, A.M.; Wray, J. Involving patient, family and medical staff in the evaluation of 3D printing models of congenital heart disease. Common. Med. 2015, 12, 157–169.
  53. Lau, I.W.W.; Liu, D.; Xu, L.; Fan, Z.; Sun, Z. Clinical value of patient-specific three-dimensional printing of congenital heart disease: Quantitative and qualitative assessments. PLoS ONE 2018, 13, e0194333.
  54. Illmann, C.F.; Hosking, M.; Harris, K.C. Utility and access to 3-dimensional printing in the context of congenital heart disease: An International physician survey study. CJC. Open 2020, 2, 207–213.
  55. Sun, Z. Cardiac CT imaging in coronary artery disease: Current status and future directions. Quant. Imaging Med. Surg. 2012, 2, 98–105.
  56. Rubin, G.D.; Leipsic, J.; Schoepf, J.U.; Fleischmann, D.; Napel, S. CT angiography after 20 years: A transformation in cardiovascular disease characterization continues to advance. Radiology 2014, 271, 633–652.
  57. Sun, Z.; Al Moudi, M.; Cao, Y. CT angiography in the diagnosis of cardiovascular disease: A transformation in cardiovascular CT practice. Quant. Imaging Med. Surg. 2014, 4, 376–396.
  58. Abdullah, K.A.; McEntee, M.F.; Reed, W.; Kench, P.L. Development of an organ-specific insert phantom generated using a 3D printer for investigations of cardiac computed tomographic protocols. J. Med. Radiat. Sci. 2018, 65, 175–183.
  59. Morup, S.D.; Stowe, J.; Precht, H.; Gervig, M.H.; Foley, S. Design of a 3D printed coronary artery model for CT optimization. Radiography 2022, 28, 426–432.
  60. Sun, Z.; Ng, C.K.C.; Wong, Y.H.; Yeong, C.H. 3D-printed coronary plaques to simulate high calcification in the coronary arteries for investigation of blooming artifacts. Biomolecules 2021, 11, 1307.
  61. Sun, Z.; Ng, C.K.; Squelch, A. Synchrotron radiation computed tomography assessment of calcified plaques and coronary stenosis with different slice thicknesses and beam energies on 3D printed coronary models. Quant. Imaging Med. Surg. 2019, 9, 6–22.
  62. Sun, Z. 3D printed coronary models offer new opportunities for developing optimal coronary CT angiography protocols in imaging coronary stents. Quant. Imaging Med. Surg. 2019, 9, 1350–1355.
  63. Sun, Z.; Jansen, S. Personalized 3D printed coronary models in coronary stenting. Quant. Imaging Med. Surg. 2019, 9, 1356–1367.
  64. Sommer, K.N.; Lyer, V.; Kumamaru, K.K.; Rava, R.A.; Ionita, C.N. Method to simulate distal flow resistance in coronary arteries in 3D printed patient specific coronary models. 3D Print. Med. 2020, 6, 19.
  65. Wu, C.; Squelch, A.; Sun, Z. Assessment of optimization of computed tomography angiography protocols for follow-up type B aortic dissection patients by using a 3D-printed model. J. 3D. Print. Med. 2022, 6, 117–127.
  66. Aldosari, S.; Jansen, S.; Sun, Z. Optimization of computed tomography pulmonary angiography protocols using 3D printed model with simulation of pulmonary embolism. Quant. Imaging Med. Surg. 2019, 9, 53–62.
  67. Aldosari, S.; Jansen, S.; Sun, Z. Patient-specific 3D printed pulmonary artery model with simulation of peripheral pulmonary embolism for developing optimal computed tomography pulmonary angiography protocols. Quant. Imaging Med. Surg. 2019, 9, 75–85.
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Subjects: Radiology, Nuclear Medicine & Medical Imaging
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Zhonghua Sun
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Cleo Wee
View Times: 365
Revisions: 2 times (View History)
Update Date: 30 Sep 2022
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