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STATE-OF-THE-ART PAPER

3D Printing to Guide Ventricular AssistDevice Placement in Adults WithCongenital Heart Disease and Heart Failure

Kanwal M. Farooqi, MD,a,b Omar Saeed, MD,c Ali Zaidi, MD,c Javier Sanz, MD,d James C. Nielsen, MD,b,e

Daphne T. Hsu, MD,f Ulrich P. Jorde, MDc

JACC: HEART FAILURE CME

This article has been selected as the month’s JACC: Heart Failure CME

activity, available online at http://www.acc.org/jacc-journals-cme by

selecting the CME tab on the top navigation bar.

Accreditation and Designation Statement

The American College of Cardiology Foundation (ACCF) is accredited by

the Accreditation Council for Continuing Medical Education (ACCME) to

provide continuing medical education for physicians.

The ACCF designates this Journal-based CME activity for a maximum

of 1 AMA PRA Category 1 Credit(s). Physicians should only claim credit

commensurate with the extent of their participation in the activity.

Method of Participation and Receipt of CME Certificate

To obtain credit for JACC: Heart Failure CME, you must:

1. Be an ACC member or JACC subscriber.

2. Carefully read the CME-designated article available online and in this

issue of the journal.

3. Answer the post-test questions. At least 2 out of the 3 questions

provided must be answered correctly to obtain CME credit.

4. Complete a brief evaluation.

5. Claim your CME credit and receive your certificate electronically by

following the instructions given at the conclusion of the activity.

CME Objective for This Article: After reading this article, the reader

should be able to discuss: 1) the prevalence of heart failure in patients

From the aDivision of Pediatric Cardiology, University Hospital, Rutgers–bDivision of Pediatric Cardiology, Mount Sinai Medical Center, Icahn SchoocDivision of Cardiology, Montefiore Medical Center, Albert Einstein College o

Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center

at Mount Sinai, New York, New York; eDivision of Pediatric Cardiology, Ston

York; and the fDivision of Pediatric Cardiology, Children’s Hospital at Montefi

York. Funding for the three-dimensional printer used to create the models wa

The authors have reported that they have no relationships relevant to the c

Manuscript received October 5, 2015; revised manuscript received Decembe

with congenital heart disease; 2) the potential role of 3D printing to

evaluate anatomical considerations for cardiovascular disease manage-

ment; and 3) the implications of these data related to clinical practice

and future research.

CME Editor Disclosures: Deputy Managing Editor Mona Fiuzat, PharmD,

FACC, has received research support from ResMed, Gilead, Critical

Diagnostics, Otsuka, and Roche Diagnostics. Tariq Ahmad, MD, MPH, has

received a travel scholarship from Thoratec. Robert Mentz, MD, has

received a travel scholarship from Thoratec; research grants from Gilead;

research support from ResMed, Otsuka, Bristol-Myers Squibb, Astra-

Zeneca, Novartis, and GlaxoSmithKline; and travel related to investigator

meetings from ResMed, Bristol-Myers Squibb, AstraZeneca, Novartis, and

GlaxoSmithKline. Adam DeVore, MD, has received research support from

the American Heart Association, Novartis Pharmaceuticals, Thoratec, and

Amgen.

Author Disclosures: Funding for the three-dimensional printer used to

create the models was provided by the Congenital Heart Defect Coalition.

The authors have reported that they have no relationships relevant to the

contents of this paper to disclose.

Medium of Participation: Print (article only); online (article and quiz).

CME Term of Approval

Issue date: April 2016

Expiration date: March 31, 2017

New Jersey Medical School, Newark, New Jersey;

l of Medicine at Mount Sinai, New York, New York;

f Medicine, Bronx, New York; dZena and Michael A.

for Cardiovascular Health, Icahn School of Medicine

ybrook University Medical Center, Stonybrook, New

ore, Albert Einstein College of Medicine, Bronx, New

s provided by the Congenital Heart Defect Coalition.

ontents of this paper to disclose.

r 30, 2015, accepted January 8, 2016.

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3D Printing to Guide Ventricular Assist

Device Placement in Adults WithCongenital Heart Disease and Heart Failure

ABSTRACT

As the population of adults with congenital heart disease continues to grow, so does the number of these patients with

heart failure. Ventricular assist devices are underutilized in adults with congenital heart disease due to their complex

anatomic arrangements and physiology. Advanced imaging techniques that may increase the utilization of mechanical

circulatory support in this population must be explored. Three-dimensional printing offers individualized structural

models that would enable pre-surgical planning of cannula and device placement in adults with congenital cardiac dis-

ease and heart failure who are candidates for such therapies. We present a review of relevant cardiac anomalies, cases in

which such models could be utilized, and some background on the cost and procedure associated with this process.

(J Am Coll Cardiol HF 2016;4:301–11) © 2016 by the American College of Cardiology Foundation.

T he size of the adult population with congen-ital heart disease (CHD) has surpassed thatof the pediatric population with CHD (1,2).

This improvement in survival reflects the success ofinnovations in congenital heart surgery. However,approximately one-quarter of these adults withcongenital heart disease (ACHD) will progress to heartfailure (HF) by 30 years of age (3). HF has been docu-mented in 22% of patients with d-transposition of thegreat arteries (d-TGA) who have had a Mustard proce-dure, 32% of patients with l-transposition of the greatarteries (l-TGA), and 40% of patients who have had aFontan procedure (4).

Ventricular assist devices (VAD) have evolved fromlarge pulsatile volume displacement pumps withlimited durability (averaging 12 to 18 months) to smallcontinuous flow left ventricular assist devices lastingnearly 10 years in individual cases (5,6). The mostrecent continuous flow left ventricular assist devicemodels are comparable in size to a golf ball andweigh <300 g; dual implantation procedures havebeen performed to provide biventricular support (7).However, the utilization of VADs in patients withCHD remains rare due to the highly variable anatomyand complex physiology in this population (8).

Three-dimensional (3D) printing is an emergingtechnology that enables creation of physical anatomicmodels from a patient’s imaging datasets. Such amodel allows the surgeon direct visualization of apatient’s 3D cardiac anatomy before entering theoperating room, thus facilitating planning of deviceand cannula placement in adults with complexcongenital lesions. The goal of the presentarticle is to review the application of 3D printing

to facilitate durable mechanical circulatory support(MCS) in some representative congenital defects thatwe believe are well suited for this technology.

THE FAILING SYSTEMIC RIGHT VENTRICLE

d-TGA AFTER ATRIAL SWITCH PROCEDURE. d-TGA re-fers to the congenital cardiac malformation in whichthere is ventriculoarterial discordance (9). In otherwords, the aorta arises from the right ventricle (RV)and the pulmonary artery from the left ventricle (LV)(Figure 1A). These neonates are cyanotic at birth, andan atrial septostomy is often needed to allowmixing of2 otherwise separate and parallel circuits (10). It is nowstandard of care to perform an arterial switch opera-tion within the first few weeks of life to establishnormal connections of the ventricles and great arteries(11). This surgery consists of the pulmonary artery andaorta being disconnected, just above the semi-lunarvalves, and then reanastomosed with the RV and LV,respectively, allowing the LV to remain as the sys-temic ventricle. The coronary arteries are also surgi-cally repositioned with the aorta.

Before this approach, an atrial switch procedure,which consisted of surgically rerouting the systemicand pulmonary venous return to the LV and RV,respectively, was used to treat these patients. Thevenous return was directed to the contralateralatrioventricular valve by creating atrial baffles, withautologous tissue in the Senning procedure or syn-thetic material in the Mustard procedure (Figure 1B)(12,13). Despite anatomically corrected blood flow,these patients are at high risk for HF due to the RVserving the systemic circulation, with approximately

AB BR E V I A T I O N S

AND ACRONYM S

3D = three-dimensional

ACHD = adult with congenital

heart disease

CHD = congenital heart disease

d-TGA = dextro-transposition

of the great arteries

HF = heart failure

l-TGA = levo-transposition of

the great arteries

LV = left ventricle

MCS = mechanical circulatory

support

RV = right ventricle

VAD = ventricular assist device

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30% developing clinical HF by 40 years of age. Oncesymptoms of HF develop, 1-year mortality approaches50% (4,14,15).

There have been only a few reports addressing theapplication of MCS in patients with d-TGA and a failingsystemic RV after an atrial switch procedure (16–20).Maly et al. (19) reported on a small series of patientswho had a HeartMate II VAD (Thoratec Corporation,Pleasanton, California) implanted as a bridge to trans-plantation. Three patients survived to undergo a hearttransplant, whereas 2 died on post-operative days30 and 502 from pump thrombosis and progressiveHF, respectively. The investigators concluded thatthe use of the VAD as a bridge to transplant is a suitableapproach in these patients with severe RV failure.One of the patients in a report by Menachem et al. (17)had undergone a Mustard procedure at 3.5 years ofage. After developing severe right ventriculardysfunction with recurrent episodes of ventriculartachycardia, a HeartMate II VAD was placed, and thepatient subsequently underwent successful cardiactransplantation. Of note, the pre-peritoneal pocketwas created in the right upper abdomen,with the pumpoutflow graft oriented in the right upper abdomenand coursed through the right chest for anastomosisto the ascending aorta. These reports illustrate thepotential utility of durableMCS in patientswith d-TGA.

FIGURE 1 d-Transposition of the Great Arteries

(A) The cardiac anatomy in dextro-transposition of the great arteries co

pulmonary artery (PA) from the left ventricle (LV). The deoxygenated blo

(red arrows) is directed to the PA, resulting in a parallel circulation. (B) T

the PA and the oxygenated blood to the AO via surgical baffles (BA). LA

l-TRANSPOSITION OF THE GREAT ARTERIES. Inpatients with l-TGA, the RV is leftwardand posterior, and there is atrioventriculardiscordance as well as ventriculoarterialdiscordance (21). This anatomic arrangementresults in deoxygenated blood traveling fromthe right atrium to the right-sided LV and thento the pulmonary artery. The oxygenatedblood from the pulmonary veins arrives in theleft atrium and then is routed to a left-sided RVand finally to the aorta (Figure 2). Because theoxygenated and deoxygenated blood flow isdirected appropriately, this malformation isreferred to as “congenitally corrected.” How-ever, as in d-TGA after atrial switch, themorphological RV is responsible for support-ing the systemic circulation. In a series of

patients with l-TGA, 25% of those without associatedlesions and 67% of patients with associated lesionsdeveloped HF by 45 years of age (22,23). Approxi-mately 13% of these adults will go on to require hearttransplantation (23). A few reports have describedtheir experience with MCS in these patients (16–18).Two subjects in the aforementioned series byMenachem et al. (17) were patients with l-TGA. Onepatient with situs inversus underwent placement of aHeartMate II VAD as destination therapy. The cardiac

nsists of the aorta (AO) arising from the right ventricle (RV) and the

od (blue arrows) is directed to the AO whereas the oxygenated blood

he Mustard or Senning procedure reroutes the deoxygenated blood to

¼ left atrium; RA ¼ right atrium.

FIGURE 2 l-Transposition of the Great Arteries

In levo-transposition of the great arteries or “congenitally corrected”

transposition of thegreat arteries, the RV is left-sided andgives rise to

theAO. In the absence of other congenital cardiac lesions, oxygenated

blood is appropriately pumped to the AO and deoxygenated blood

to the PA. However, this anatomic arrangement results in the RV

serving as the systemic ventricle. Abbreviations as in Figure 1.

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apex was at the right axillary line, requiring rotation ofthe anterior aspect of the VAD by 180 degrees.This procedure allowed placement of the apicalcannula in the systemic RV. The power source was alsoswitched to arise from the left upper abdomen. Thepatient did well in the early post-operative period butdied of subdural and subarachnoid hemorrhage. Theother patient developed advanced cardiomyopathyand had refractory ventricular arrhythmia withdeclining functional status. Due to progressive symp-toms and dependence on inotropic support, she waslisted for transplantation but was highly allosensitizedand so was considered for VAD placement. She un-derwent placement of a HeartWare VAD (HeartWareInc., Framingham, Massachusetts) for refractory HF.The procedure was done through a median sternot-omy, and once the device was connected to the sys-temic RV, the HVAD outflow cannula was directedtoward the leftward pleural space because of the left-ward aorta. This patient did well and was dischargedon oral diuretic agents.

BARRIERS TO VAD PLACEMENT IN d-TGA AND

l-TGA. There are numerous anatomic factors that mayplay a role in complicating VAD placement in patients

with a systemic RV. The right ventricular apex is not aswell developed as the left ventricular apex, and thusthere may be more difficulty identifying the ideal siteof inflow cannula insertion. In patients with severeHF, the right ventricular dilation may cause distortionof the ventricle, further making this delineation chal-lenging. The presence of trabeculations and themoderator band, specific to the RV, introduce possiblesources of inflow obstruction, especially if placedas traditionally done at the ventricular “dimple.”Mostgroups perform an aggressive resection of thesestructures to avoid this complication and place thecannula more posteriorly (18). Rotation of the VADby 180 degrees in patients with l-TGA may make pos-terior placement simpler (17). Extensive scarring ofthe mediastinum and abnormal hemodynamics offerfurther challenges to VAD placement (24,25).

Although patients with both d-TGA and l-TGAexperience systemic RV failure, the anatomic locationof the ventricle is very different. In patients withd-TGA, the RV is anterior and rightward as in a normalheart, whereas in l-TGA, it is leftward and posterior,in the usual left ventricular position. In thesepatients, placement of a VAD in the right abdomeninstead of the left can cause compression of right-sidedstructures, which must be monitored in the post-operative setting (26). These anatomic considerationsagain highlight the uniqueness of these patients.During consideration for VAD placement in patientswho have had an atrial switch procedure, care must betaken to assess for baffle leaks or obstruction thatmightresult in cyanosis or inadequate flow. Interestingly,an aspect in which placement of a right-sided VAD issomewhat less complicated seems to be the lack ofsubsequent failure of the opposite ventricle (ie, LV).Remarkably, the LV seems to be less susceptible to thepost-VAD changes that often cause right ventricularfailure in patients after left ventricular assist deviceplacement in the LV (17).

HF AFTER FONTAN PALLIATION. The Fontan pallia-tion is a surgical option offered to patients whoseanatomy is not amenable to support a 2-ventricle cir-culation. In most cases, 1 of the ventricles is severelyunderdeveloped and unable to support either thepulmonary or systemic circulation. This palliation al-lows systemic venous return to be diverted directly tothe pulmonary arteries, rendering the single ventriclesolely responsible for pumping oxygenated blood tothe systemic circulation (27). The CHDs that warrantsuch an intervention are numerous and include hypo-plastic left heart syndrome, tricuspid atresia, anddouble inlet LV. The interventions consist of a 3-stagepalliation that is completed at approximately 3 years

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of age. Once complete, the venous blood flow is pro-vided passively to the pulmonary arteries by directsurgical anastomosis, from the superior and inferiorvena cava. The functional ventricle, either a morpho-logical RV or LV (which varies depending on the pa-tient’s diagnosis), supplies the systemic blood flow.Although this innovative surgical approach offerssurvival to patients whose demise was previouslyinevitable, the Fontan procedure continues to beconsidered a palliation rather than a cure and is asso-ciated with long-term morbidity (28). Incidence ofFontan failure is approximately 30% at 20-year follow-up, suggesting that earlier options for appropriatetreatment of HF need to be identified for these patients(29). Common morbidities in this population includean increased risk of thromboembolism, protein-losingenteropathy, plastic bronchitis, bleeding complica-tions, atrial arrhythmias, and liver cirrhosis (30,31).

In patients with a failing Fontan circulation, poornutritional status and organ dysfunction make themimperfect candidates for a much-needed cardiactransplantation. A handful of groups have reportedon VAD placement, into either the right-sided circu-lation or the systemic ventricle, to rehabilitate thesepatients (32–35). A Berlin Heart (Berlin Heart GmbH,Berlin, Germany) was inserted into the right-sidedcirculation in a case reported by Prêtre et al. (32).Although the patient had good systolic function of thesystemic ventricle and atrioventricular valve, he dis-played signs of right atrial dilation, arrhythmia, andrenal and hepatic failure. To create an inflow andoutflow site, the cavopulmonary anastomosis wastaken down, and 2 new “chambers” were surgicallycreated. The inflow cannula was connected to thechamber that received systemic venous flow. Thiswas separated from the pulmonary artery to whichthe outflow cannula was connected. The cannulaswere then connected at the skin to a Berlin Heart.This patient recovered remarkably with improvementin organ function and resolution of ascites. He un-derwent a transplant 13 months later. In patients withpoor systemic ventricular function, left VAD place-ment with the inflow cannula placed in the ventricleand outflow into the ascending aorta has beenreported, with good outcomes (34). Clearly, theapproach to MCS placement in these patients must beindividualized. As the few reported cases illustrate,approach to cannula and device placement is heavilydependent on the source of HF as well as the specificcongenital malformation.

BARRIERS TO VAD PLACEMENT IN FONTAN CIRCU-

LATION. In patients with a univentricular circula-tion, the clinical status will govern the anatomic

placement of the VAD. In patients with good systemicventricular function, surgical considerations includethe method of separation of the systemic venous andpulmonary circulation with takedown of the cav-opulmonary anastomosis. Before the patient is takento the operating room, the presence of Fontan circuitleaks or stenosis must be assessed, as well as anystenosis of the pulmonary arteries.

The variable approaches to device and cannulaplacement in patients with ACHD and HF highlightthe challenge of application of MCS in these patients.3D printing is a technique that can offer additionalanatomic information to aid in pre-surgical planningand in effect decrease some of the potential difficultyassociated with offering VAD therapies in thispopulation.

THE ABCs OF 3D PRINTING

The technology of 3D printing, also referred to as rapidprototyping, additive manufacturing, or stereo-lithography, was first patented in 1986 by Charles Hull.The process of creating a 3D physical structure by us-ing a 3D printer involves first creating a virtual 3Dobject from a 3D image dataset, using a method calledsegmentation. This 3D file can then be translated into aphysical 3D object by using various techniquesdepending on the type of printer used (CentralIllustration). Printers using fusion depositionmodeling, for example, use a nozzle to extrude thinlayers of a liquefied thermoplastic sequentially onto aplatform. Stereolithographic printers utilize a laserbeam directed at a basin of liquid photopolymer tosequentially solidify layers onto a platform, which isslowly raised.

The capabilities of printers vary widely in terms ofthe largest size model that may be printed (build vol-ume), layer resolution, material used for printing, andsupport material solubility. Support material is prin-ted with the model to protect any overhanging partsfrom collapsing before solidifying. Some printers havethe ability to print in different colors within the samemodel, which can be useful, for example, whenprinting tumors within the myocardium (36). Spe-cialties ranging from orthopedics to cardiology areapplying this technology to create patient-specificmodels to aid in pre-surgical planning (37–39).

3D PRINTING IN HF PATIENTSWITHOUT CHD. In patientswith HF without CHD, a 3D printed model can also beuseful in planning surgical management. In adultswith mitral valvulopathy, a 3D printed model of thevalve can be used to assess the specific mechanism ofregurgitation (40,41). In patients with aortic stenosis

CENTRAL ILLUSTRATION Workflow Associated With Creating a 3D Cardiac Model

A sample of workflow is shown diagrammatically from identification of adults with congenital heart disease and heart failure (ACHD-HF) to image acquisition and

creation of a virtual and three-dimensional (3D) printed solid model. This model is used by the cardiac and surgical teams for pre-procedural planning before

ventricular assist device (VAD) placement. d-TGA ¼ dextro-transposition of the great arteries; l-TGA ¼ levo-transposition of the great arteries.

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who are candidates for transcatheter aortic valvereplacement, the left ventricular outflow tract can beprinted for pre-procedural planning (42).

3D PRINTING IN HF PATIENTS WITH CHD. Applica-tions in pediatric patients with CHD include visual-izing intracardiac spatial anatomy for repair of adouble outlet RV, ventricular septal defects, andtetralogy of Fallot with major aortopulmonarycollateral arteries (43–45). Interestingly, there is areport of the technology being used in developmentof an axial flow VAD more than a decade ago (46).

With the number of adults with CHD and HF un-doubtedly set to increase over time, strong consid-eration must be given to methods that will allow us tomore readily offer therapies such as MCS. We arehopeful that the approach of creating 3D printed

patient-specific cardiac models in these patients willnarrow the wide gap between patients with andwithout CHD being offered these potentially life-extending therapies.

CLINICAL EXAMPLES OF PATIENTS WITH ACHD-HF

AND 3D PRINTED CARDIAC MODELS. Pat ient #1 . A36-year-old male patient with d-TGA had undergone aMustard procedure at 5 years of age. A pulmonaryvenous baffle revision was performed 2 years later torelieve a baffle obstruction. The patient underwentpacemaker placement for sick sinus syndrome at15 years of age. He had a history of an emboliccerebrovascular accident with residual right-sidedweakness. He developed gradual severe RV failureand was classified as New York Heart Associationfunctional class III at the time a cardiac magnetic

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resonance scan was performed. The magnetic reso-nance angiography image dataset was used to createthe virtual 3D model (Materialise, Leuven, Belgium),which was subsequently printed on a desktop 3D

FIGURE 3 d-TGA of the Pulmonary Arteries

3D Model of patient after Mustard procedure A three-dimensional (3D)

pulmonary venous baffle (PVB) to the systemic RV in a 36-year-old patie

procedure in heart failure. The model is viewed from (A) the anterior as

(i.e., the prominent trabeculations of the systemic RV and the moderato

surgical planning of cannula placement to avoid possible inflow obstruct

abbreviations as in Figure 1.

printer (Mojo, Stratasys, Eden Prairie, Minnesota).The pulmonary venous baffle anatomy was isolatedand printed, which included the severely dilatedsystemic RV (Figure 3).

virtual model (left) and corresponding printed model (right) of the

nt with dextro-transposition of the great arteries (d-TGA) s/p Mustard

pect and (B) the leftward aspect. The anatomic landmarks of interest

r band [MB]) were well reproduced. This procedure would allow pre-

ion due to these trabeculations. RVC ¼ right ventricular cavity; other

FIGURE 4 3D Model of Patient With a Systemic Right Ventricle

A 3D virtual model (left) and corresponding printed model (right) in a 51-year-old patient with l-transposition of the great arteries (l-TGA) in

heart failure. The model is viewed from (A) the anterior aspect and (B) the leftward aspect. The prominent systemic right ventricular trabe-

culations and an anterior and leftward aorta are clearly identified, allowing accurate pre-surgical planning. SVC ¼ superior vena cava; other

abbreviations as in Figures 1 and 3.

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Interestingly, this patient had a HeartWare VADplaced in the systemic RV before the 3D printed modelwas created, as a bridge to transplant. There wasspecial attention paid to the positioning of the inflow

cannula in the systemic RV to avoid flow obstructionfrom heavy trabeculations or tricuspid valve tissue.Although the 3D model was not available beforeimplantation, it could assist in placement of the inflow

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cannula to avoid interference from nearby struc-tures and maintain optimal ventricular unloading.Unfortunately, the patient died of sepsis and multi-organ failure 247 days after placement of the VAD.

Patient #2. A 51-year-old patient with l-TGA and mildto moderate systemic atrioventricular valve regurgi-tation demonstrated clinical signs of HF for about1 year. He reported dyspnea on exertion, palpitations,fatigue, and lower extremity edema. His comorbid-ities include hyperlipidemia and type 2 diabetesmellitus. The systemic RV was severely hyper-trophied, moderately dilated, and had moderate

FIGURE 5 3D Model of a Patient After Fontan Operation

A 3D virtual model (left) and corresponding printedmodel (right) in a 37-yea

procedure with persistent ascites, and atrial arrhythmias. The model is viewe

pathway (FP) and its spatial relationship with the rest of the anatomy is well

using any of the techniquesmentioned earlier. LPA¼ left pulmonary artery; R

systolic and diastolic dysfunction. The patient un-derwent a cardiac computed tomography scan thatwas used to create the virtual 3D model (Materi-alise), which was subsequently printed on a desktop3D printer (Mojo) (Figure 4).

Pat ient #3 . A 37-year-old patient with a diagnosis oftricuspid atresia and d-TGA had undergone Fontanpalliation at 7 years of age. Due to atrial arrhythmias,she required a Maze procedure with epicardial pace-maker placement. At 28 years of age, she underwentan extracardiac Fontan revision but continuedto have significant ascites and atrial arrhythmias.

r-old patient with tricuspid atresia, D-transposed great vessels s/p Fontan

d from (A) the anterior aspect and (B) the posterior aspect. The Fontan

represented on the 3D model and can be used to plan VAD placement

PA¼ right pulmonary artery; other abbreviations as in Figures 1, 3, and 4.

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She underwent a cardiac computed tomography scanthat was used to create the virtual 3D model (Mate-rialise), which was subsequently printed on a desktop3D printer (Mojo) (Figure 5).

CHOICE OF SOURCE IMAGE DATASET. The choice ofsource image dataset is dependent on multiple fac-tors. A cardiac computed tomography scan is able toprovide images with high spatial resolution acquiredin a short period of time. However, obtaining imageswith good blood-to-myocardium contrast requiresadministration of nephrotoxic iodinated contrast andexposure of the patient to radiation. Magnetic reso-nance lacks radiation exposure and can offer goodblood-to-myocardium distinction with or withoutcontrast. The study is much longer, however, andoften requires sedation for younger patients. A goodquality model can be created from either type of 3Ddataset, and specific attention must be given to thestudy that the patient would tolerate best andtherefore result in the best image dataset.

COST OF CREATING MODELS. The cost of creatinga 3D-printed cardiac model is affected by the post-processing software, personnel needed to performthe segmentation, the 3D printer, and material costs.The printer we used was the Mojo, a desktop printerwhich costs approximately $5,000. The materialcost for this printer is typically about $5 per cubicinch for an acrylonitrile butadiene styrene plastic.The range of cost for 3D printers starts at a fewhundred dollars but can easily reach more than$100,000 for larger industrial size printers (47,48).

To reduce material use, 3D cardiac models can beprinted on a smaller scale. The models printed for our

patients were 33% of the full heart size and used arange of 0.4 to 0.7 in3 of material.

THE FUTURE OF 3D PRINTING

3D printing has proven to be a promising technology,with exciting potential applications for medicine. Itprovides the opportunity to hold physical replicas of apatients’ anatomy in our hand before entering theoperating room. In patients in need of MCS, it maysoon be possible to print a patient-specific life-sizecardiac model and subsequently print a functioningVAD personalized to that patient’s anatomy. In therealm of bioprinting, which involves laying down livecells on a scaffold, the possibilities seem to stretch asfar as the imagination. Considering that the overallresponse to this technology from the medical com-munity, especially surgeons, has been positive, themain barriers to more widespread use are largelytechnical (i.e. access to postprocessing software,knowledge of skillful post-processing, availability ofgood image datasets, access to a 3D printer). With theenthusiasm for this technology comes the need forstandardization of technique, establishment of clin-ical utility, and increases in accessibility. These arehurdles that are not insignificant and with the steepincrease in research being done we will hopefullymake further strides in this field in the near future.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Kanwal M. Farooqi, Rutgers–New Jersey Medical School,185 SouthOrange Avenue,MSB-F512, Newark, New Jersey07103. E-mail: kanwal.farooqi@rutgers.edu.

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KEY WORDS 3D printing, adult congenitalheart disease, heart failure, ventricular assistdevice

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