Congenital Heart Surgery Skill Training Using Simulation Models: Not an Option but a Necessity

Role of 3D printing in healthcare: A comprehensive review on treatment and training

Additive manufacturing (AM) is revolutionizing healthcare by enabling the creation of customized 3D printed (3DP) medical equipment, implants, orthoses, prosthetics, drugs, and organs. With the availability of different types of materials suitable for 3DP and healthcare applications, this technology allows for the precise fabrication of patient-oriented prosthetics, dental implants, and orthopedic devices, significantly improving fit and functionality. Additionally, 3DP drugs, such as Oral Dispersible Formulations (ODFs) and polypills, are surpassing the traditional "one pill fits all" concept, offering more tailored medication solutions. This innovation also supports the development of personalized medications and bioprinted tissues, opening the way for advancements in regenerative medications and tailored therapies. 3D-bioprinted organs are addressing the growing demand for organ transplants. In surgical planning, 3D-printed anatomical models provide students and professionals with hands-on practice, which is crucial for skill development and understanding complex anatomies. Surgeons can also practice and refine techniques before actual procedures, enhancing precision and improving outcomes during real operations. This paper focus on highlighting the progression and motivations behind the cross-disciplinary applications of AM within the healthcare sector providing customized medical devices, drug delivery systems and diagnostic tools for personalized treatment and skill refinement. This paper is designed for a broad audience, including manufacturing professionals and researchers, who are interested in exploring the medical implications of this transformative technology.

Evaluation of the Efficacy and Accuracy of Super-Flexible Three-Dimensional Heart Models of Congenital Heart Disease Made via Stereolithography Printing and Vacuum Casting: A Multicenter Clinical Trial

Three-dimensional (3D) printing is an advanced technology for accurately understanding anatomy and supporting the successful surgical management of complex congenital heart disease (CHD). We aimed to evaluate whether our super-flexible 3D heart models could facilitate preoperative decision-making and surgical simulation for complex CHD. The super-flexible heart models were fabricated by stereolithography 3D printing of the internal and external contours of the heart from cardiac computed tomography (CT) data, followed by vacuum casting with a polyurethane material similar in elasticity to a child's heart. Nineteen pediatric patients with complex CHD were enrolled (median age, 10 months). The primary endpoint was defined as the percentage of patients rated as "essential" on the surgeons' postoperative 5-point Likert scale. The accuracy of the models was validated by a non-destructive method using industrial CT. The super-flexible heart models allowed detailed anatomical diagnosis and simulated surgery with incisions and sutures. Thirteen patients (68.4%) were classified as "essential" by the primary surgeons after surgery, with a 95% confidence interval of 43.4-87.4%, meeting the primary endpoint. The product error within 90% of the total external and internal surfaces was 0.54 ± 0.21 mm. The super-flexible 3D heart models are accurate, reliable, and useful tools to assist surgeons in decision-making and allow for preoperative simulation in CHD.

Analysis and Visualization of Inter-/Intra-surgeon Variability Using Surgical Simulation for Partial Anomalous Pulmonary Venous Connection Repair

There may be inter-/intra-surgeon variability in the repair of congenital heart defects. The objective was to analyze and visualize inter-/intra-surgeon variability in the level of patch suture lines and in the shape and size of patches developed through surgical simulation for partial anomalous pulmonary venous connection (PAPVC) repair using a patient-specific 3D-printed heart model. A patient with PAPVC and preoperative computed tomography data were selected, and a patient-specific heart model was obtained. Two different exposures on the model were tested. Two surgeons were enrolled. Both surgeons performed a single-patch repair on four heart models with one exposure and four models with the other. On the potential suture line, 20 points common in each model were allocated. The level of patch suture lines was represented as a deviation from the 20 points. The shape and size of the patches were analyzed and visualized using geometric morphometrics approaches, using the 20 points as landmarks to represent the patches. There was inter-surgeon variability in the level of patch suture lines, and the variability was higher in particular locations. There was inter-surgeon variability in the shape and size of patches, which was not affected by the exposures. The inter-surgeon variability in the shape of patches was higher in particular locations. There was intra-surgeon variability in the shape of patches. Inter-/intra-surgeon variability was analyzed and visualized by the surgical simulation using geometric morphometrics approaches. Further studies are needed to scrutinize whether the variability affects postoperative hemodynamics in actual surgery.

Longitudinal Evaluation of Congenital Cardiovascular Surgical Performance and Skills Retention Using Silicone-Molded Heart Models

Objective: Hands-on surgical training (HOST) for congenital heart surgery (CHS), utilizing silicone-molded models created from 3D-printing of patients' imaging data, was shown to improve surgical skills. However, the impact of repetition and frequency of repetition in retaining skills has not been previously investigated. We aimed to longitudinally evaluate the outcome for HOST on two example procedures of different technical difficulties with repeated attempts over a 15-week period. Methods: Five CHS trainees were prospectively recruited. Repair of coarctation of the aorta (CoA) and arterial switch operation (ASO) were selected as example procedures of relatively low and high technical difficulty. Procedural time and technical performance (using procedure-specific assessment tools by the participant, a peer-reviewer, and the proctor) were measured. Results: Coarctation repair performance scores improved after the first repetition but remained unchanged at the follow-up session. Likewise, CoA procedural time showed an early reduction but then remained stable (mean [standard deviation]: 29[14] vs 25[15] vs 23[9] min at 0, 1, and 4 weeks). Conversely, ASO performance scores improved during the first repetitions, but decreased after a longer time delay (>9 weeks). Arterial switch operation procedural time showed modest improvements across simulations but significantly reduced from the first to the last attempt: 119[20] versus 106[28] min at 0 and 15 weeks, P = .049. Conclusions: Complex procedures require multiple HOST repetitions, without excessive time delay to maintain long-term skills improvement. Conversely, a single session may be planned for simple procedures to achieve satisfactory medium-term results. Importantly, a consistent reduction in procedural times was recorded, supporting increased surgical efficiency.

Patient-Specific 3D-Printed Models in Pediatric Congenital Heart Disease

Three-dimensional (3D) printing technology has become increasingly used in the medical field, with reports demonstrating its superior advantages in both educational and clinical value when compared with standard image visualizations or current diagnostic approaches. Patient-specific or personalized 3D printed models serve as a valuable tool in cardiovascular disease because of the difficulty associated with comprehending cardiovascular anatomy and pathology on 2D flat screens. Additionally, the added value of using 3D-printed models is especially apparent in congenital heart disease (CHD), due to its wide spectrum of anomalies and its complexity. This review provides an overview of 3D-printed models in pediatric CHD, with a focus on educational value for medical students or graduates, clinical applications such as pre-operative planning and simulation of congenital heart surgical procedures, and communication between physicians and patients/parents of patients and between colleagues in the diagnosis and treatment of CHD. Limitations and perspectives on future research directions for the application of 3D printing technology into pediatric cardiology practice are highlighted.