12/07/2020
How 3D Printing Can Optimize Care for Patients with Primary Tricuspid Valve Disease
Patient-specific 3D-printed models—as are produced by Lerner Research Institute’s Medical Device Solutions (MDS)—are immensely helpful for comprehensive anatomical assessment, presurgical planning and patient education in the setting of isolated primary tricuspid valve (TV) disease.
That’s the conclusion of a new image-rich case series published in JACC: Case Reports by an interdisciplinary Cleveland Clinic team, including Ryan Klatte, a principal research engineer in the Engineering & Design Core (part of MDS). MDS routinely offers surgical planning support to care teams at Cleveland Clinic, including for the world’s first total face transplant.
A tool to facilitate patient communication
The article features case vignettes of four patients who recently underwent successful surgical repair for primary TV disease at Cleveland Clinic, with each surgery guided by a patient-specific 3D-printed TV replica. The replicas were generated from 3D transesophageal echocardiography and contrast-enhanced 4D computed tomography. Three of the four patients had severe tricuspid regurgitation (the valve does not close tightly enough and causes blood to flow back into the right upper heart chamber), and one had severe tricuspid stenosis (the valve opening narrows and reduces blood flow from the right upper chamber to the lower chamber). Surgical results were excellent in all patients.
In all four cases, the cardiologist and surgeon shared the 3D-printed model with the patient preoperatively to explain their valve disease and illustrate the expected repair. “All the patients expressed a greatly improved understanding of their disease and the planned operation. Beyond helping us plan the operation, 3D-printed models can greatly enhance patient education and potentially ease patient anxiety about their procedure,” said Serge Harb, MD, a cardiologist in the Heart, Vascular & Thoracic Institute and the study’s lead author.
Surgical planning benefits: Visualization and patient-specific anatomic understanding
“Isolated primary tricuspid valve disease is a rare entity, as it accounts for about 10 percent of all cases of tricuspid regurgitation,” said Dr. Harb. As a result, experience with surgical repair of primary TV disease is limited, which makes imaging-based preoperative planning critical. “However, the complexity of the tricuspid valve anatomy—such as its position in the chest, its thin and variable leaflets and shadowing from device leads—often makes accurate imaging of the disease a challenge.”
That’s where 3D-printed models—developed with high-spatial-resolution cardiac imaging and advanced image-processing software—prove valuable, as they provide a more detailed analysis of the TV leaflets and an accurate depiction of the TV annulus (fibrous structure that provides support for the valve) and right ventricle morphology.
“Surgery for isolated tricuspid valve disease carries a postoperative mortality rate of up to nearly nine percent in the Western world,” noted cardiothoracic surgeon Per Wierup, MD, PhD, a co-author of the case series. He added that the operative complexity and prolonged extracorporeal circulation (circulation of blood outside the body through artificial organs) heighten risk of vasoplegia (low systemic vascular resistance) and coagulopathy (blood clotting disorder) in particular. Underlying right ventricular and liver and/or kidney dysfunction in cases with late presentation also raise the risk of postoperative multi-organ failure.
“The enhanced visualization and anatomic understanding to be derived from 3D-printed models help us optimize our presurgical plan, customize the operation to the patient’s unique anatomy, anticipate potential complications, and reduce operative and extracorporeal circulation times,” added Dr. Wierup. “This substantially reduces the risks for our patients.”
Images: (Top) Tricuspid valve and pacemaker leads visualized from the right atrium in a woman in her 20s with severe tricuspid stenosis who had a dual-chamber pacemaker to treat a congenital complete heart block; (Bottom) Tricuspid valve (in green) printed in systole in a 66-year-old woman with severe tricuspid regurgitation with prolapse of the topmost valve leaflet.