CardioSource WorldNews | Patients with congenital heart disease present a number of unique challenges for heart surgeons. Advances in 3D printing technology could be poised to play a supporting role in ventricular assist device placement for these patients. A recent JACC: Heart Failure study explores this idea further. In this interview from ACC.16 in Chicago, CSWN Executive Editor Rick McGuire talks with paper co-author Ulrich P. Jorde, MD, section head of the heart failure cardiac transplantation and mechanical circulatory support at Montefiore Medical Center, New York City, NY.

CSWN: This is a fun topic. We did a cover story on 3D printing 1 year ago, and this just seems to be an ideal setting for it.

Ulrich P. Jorde, MD: I think so, too. This is a very exciting time because two things are converging. First, we have a lot more patients (unfortunate patients with congenital heart disease), who, in the past, used to simply die.

Nowadays, through great advances in diagnosis and surgical maneuvering, [these patients] see their life lengthened. At this moment in time, there are actually more adult congenital heart patients than children, and these patients, unfortunately, will develop congestive heart failure (HF). In comes mechanical circulatory support, evolved over the past decades from large, bulky, clunky pumps to now very small, golf-ball-size mechanical circulatory-support devices that can be used in these patients.

Congenital heart disease patients pose unique challenges, as the anatomy is completely different from a regular mechanical-support patient. In the regular mechanical circulatory support (MCS) world, we have learned to illustrate the issues, the extreme importance of placing the device in the right spot, and placing the cannula within the normal left ventricule (which is dilated) in the right spot. You can imagine how, in congenital heart disease, this is a much bigger challenge.

A typical example would be a situation where the right ventricle, which is more heavily trabeculated than the left, has become the systemic ventricle, yet needs to support systemic circulation. Here, regular insertion of a cannula will basically embed the cannula in trabeculations. There are few cases where this has been done, and the surgeons have had a learning curve where they now know to cut away some of the trabeculations to put in the cannula. But this is just the very beginning.

Now we’re moving from transposition of the great artery cases that are fairly straight forward with the right ventricle to situations with a Fontan circulation, for example, where the patient has had two or three surgeries in the past and now the pump is failing. In these patients, what we have done (and reported in our paper) is to [create] 3D-printed hearts with all their congenital abnormalities. We believe that direct inspection by the surgeon (in a life-sized model) could inform [the surgeon] prior to the operating room, and prior to finding unforeseen surprises [when searching for] where exactly to place the left ventricular assist device. Taking this to the next level, I can foresee that we would print life-sized hearts [to create] custom-designed assist devices, and find solutions for patients with congenital heart disease.

In your review, you actually go through the ABCs of 3D printing. What does someone have to know in order to just get this idea in mind of coming up with this 3D package?

There is a cost spectrum, and we address this in the article. We were actually asked to do this, which I think was an excellent suggestion by the editors.

We used a relatively cheap printer that only cost $5,000. You can do this with slightly cheaper printers, but [the cost] goes up. You can spend hundreds of thousands of dollars to get really beautiful replicas of these hearts (I should also say that the technology itself isn’t detailed or summarized in our article). If you have the equipment, most people would be able to do this. At this moment, it still requires a person that really knows how to use the software. Most credit for this paper, I think, goes to Kanwal Farooqi, MD, who is the first author on our paper and a pediatric cardiologist. It can be done, and I think it will become commonplace for these procedures.

Walk us through your review. You cover a variety of different topics on how this might work.

I have to start by admitting that, as a regular adult cardiologist, congenital heart disease is not something that I am as intimately familiar with as mechanical circulatory support itself. So in this review, we have outlined several standard situations: D and L transposition of the great arteries (which come with different position of the left ventricle inside the chest and different role of the morphological ventricles inside the heart). We have also shown a nice 3D printing of a Fontan circulation where a patient had a Mustard procedure in the past, and now mechanical circulatory support is considered. We printed out the entire baffle of this heart so we could orient ourselves within it, but also were able to [evaluate] outside on the table where the blood would flow and what obstructions there might be.

Do you think that this is going to start being more widely used within the next 5 years?

I think right now it is a little bit like what we went through with mechanical circulatory support itself where, say, 5 or 10 years ago, there were only maybe 500 to 700 implants in the United States. People saw patients with very advanced HF and they simply said, “That’s it.” Admittedly, the technology 10 years ago was not where it is now. I am certain that at this very moment in time, there is a very large number of patients with transposition of the great arteries (with Fontan circulation) where mechanical circulatory support could be attempted and could possibly lead them to a situation where they get a heart transplant in the future, or where they can live with mechanical circulatory support like many destination therapy patients do right now.

For me, this was completely new. This was a really new adventure. It’s a concept. Right now, I think we are largely agnostic as to which patients can benefit from mechanical support. So we are extremely excited that we’re reaching the readers of JACC: Heart Failure, and they hopefully will spread the word. Don’t give up. Let’s move to the next level.

Reference

1. Kanwal M, Saeed O, Zaidi A, et al. JCHF. 2016;4:301-11.

Read the full June issue of CardioSource WorldNews at ACC.org/CSWN

Keywords: CardioSource WorldNews, Heart Defects, Congenital, Heart Failure, Heart Ventricles, Heart-Assist Devices

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