Interventional Treatment of Recurrent Ventricular Septal Defect Planed by 3D-Printed Reconstruction of the Heart

Abstract

We report a complex case of a 53-year-old male patient with recurrent ischemic ventricular septal defect that had been occluded by a surgical patch. Treatment was accomplished utilizing a 3-dimensional-printed model for preprocedural planning. In the future, printing of 3-dimensional models could offer new therapeutic strategies on an individual level. (Level of Difficulty: Intermediate.).

Full text

CASE REPORT
CLINICAL CASE
Interventional Treatment of Recurrent
Ventricular Septal Defect Planed by
3D-Printed Reconstruction of the Heart
Felix J. Hofmann, MD,
a
Oliver Dörr, MD,
a
Bernd Abt, MD,
b
Tibor N. Jung, MSC,
c
Martin Luduena, MD,
d
Andreas Rolf, PD,
e
Keywan Sohrabi, MD,
c,f
Pawel Staszewicz, MD,
b
Ardawan J. Rastan, MD,
d
Holger M. Nef, MD
a,g
ABSTRACT
We report a complex case of a 53-year-old male patient with recurrent ischemic ventricular septal defect that had
been occluded by a surgical patch. Treatment was accomplished utilizing a 3-dimensional–printed model for
preprocedural planning. In the future, printing of 3-dimensional models could offer new therapeutic strategies on
an individual level. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2023;11:101789) © 2023 The
Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
BACKGROUND
Ischemic ventricular septal defects (iVSDs) are rare
but severe complications of myocardial infarction
(0.2%) that are associated with high mortality
rates.
1,2
Medical treatment alone is associated with
a poor outcome; thus, the current state of the art is
mechanical closure using surgery or interventional
methods.
3
Surgical closure of the defect is often
complex even in nonacute conditions.
4
Neverthe-
less, there are a small number of device or therapy
failures, which makes a renewed therapy even more
complex. There are no specificdevicesavailablefor
such a condition, so standard interventional devices
have been used for treatment. Hence, the perfor-
mance of these devices in vivo is difficult to pre-
dict, resulting in an incalculable outcome.
4
Recent
developments in cardiac imaging and 3-dimensional
(3D) printing potentially allow strategies and simu-
lation of the device performance on an individual
basis.
5
We report a case in which 3D printing was
used to plan the optimal treatment strategy for
recurrent ventricular septal defect (VSD) after sur-
gical correction failed.
LEARNING OBJECTIVES
To utilize a 3D-printed model of the heart to
perform preprocedural strategy planning and
device selection in nonroutine iVSD closure
conditions.
To make interventional therapy more
personalized using new therapeutic strate-
gies on an individual patient basis, especially
in complex cases.
ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2023.101789
From the
a
Department of Cardiology, University of Giessen, Giessen, Germany;
b
Department of Cardiology, Herz-Kreislauf-
Zentrum Klinikum Hersfeld-Rotenburg, Rotenburg an der Fulda, Germany;
c
Faculty of Health Sciences, University of Applied
Sciences, Giessen, Germany;
d
Department of Heart Surgery, Herz-Kreislauf-Zentrum Klinikum Hersfeld-Rotenburg, Rotenburg an
der Fulda, Germany;
e
Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany;
f
Institute of Medical Infor-
matics, University of Giessen, Giessen, Germany; and the
g
German Center for Cardiovascular Research, partner site Rhine-Main,
Bad Nauheim, Germany.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.
Manuscript received January 23, 2023; accepted February 1, 2023.
JACC: CASE REPORTS VOL. 11, 2023
ª2023 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN
COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER
THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).

HISTORY OF PRESENTATION
A 53-year-old male patient presented with
symptoms of dyspnea and was referred to our
center.
PAST MEDICAL HISTORY
He had had a previous ST-segment eleva-
tion myocardial infarction with 3-vessel coronary
artery disease and iVSD and had undergone surgical
myocardial revascularization (left internal mammary
artery to left anterior descending coronary artery,
right internal mammary artery as T graft to right
circumflex and posterior left ventricular branch) as
well as placement of a pericardial iVSD patch
in 2021.
INVESTIGATIONS
After several months, echocardiography revealed
recurrence of the iVSD and the left-to-right (L-R)
shunt due to insufficient pericardial patch
closure (Video 1). Repeat coronary angiography
ruled out progression of coronary disease. Venous
cardiac catheterization showed mild precapillary
pulmonary hypertension (mean pulmonary artery
pressure: 26 mm Hg; pulmonary vascular resistance:
160 dynes/s/cm
5
; pulmonary capillary wedge pres-
sure:13mmHg),normalcardiacoutput,anda
significant L-R shunt of 3.26 (Qp:Qs). The local heart
team made the decision to perform interventional
iVSD closure.
MANAGEMENT
For preprocedural preparation, contrast agent
electrocardiography–triggered cardiac computed to-
mography was performed showing the iVSD (Figure 1).
This was followed by active contour, pixel-oriented,
and region-oriented segmentation to create a 3D
model of the heart in standard transformation lan-
guage format (Figures 2 and 3). The model was then
printed using additive printing with elastic synthetic
FIGURE 1 Cardiac Computed Tomography Showing the Ischemic Ventricular Septal Defect
Cardiac computed tomography showing the ischemic ventricular septal defect (red arrows) in different views.
ABBREVIATIONS
AND ACRONYMS
ASD =atrial septal defect
iVSD =ischemic ventricular
septal defect
L-R =left to right
VSD =ventricular septal defect
3D =3-dimensional
Hofmann et al JACC: CASE REPORTS, VOL. 11, 2023
Interventional Treatment of Recurrent VSD Planed by 3D-Printed Reconstruction of the Heart APRIL 5, 2023:101789
2

resin (shore hardness 80A) in a stereolithographic 3D
printer (Formlabs Form 3, Formlabs GmbH) (Figure 4).
The next step was to test different VSD and atrial
septal defect (ASD) closure devices, which was carried
out by condensing the procedure to wiring and im-
plantation of the devices in the 3D model. While one
VSD post–myocardial infarction muscular occluder
showed unfavorable results with deformation and
protrusion of either the left or right ventricle
(Amplatzer Muscular VSD P.I. Occluder 9 mm, Abbott
Laboratories) (Figure 5A), 2 ASD closure devices, with
smaller waists and greater disc diameters, showed
better results (Amplatzer Multifenestrated Septal
Occluder–Cribriform; Abbott Laboratories). Testing of
2 sizes (25 and 30 mm) revealed that the 25-mm ASD
was the most appropriate (Figures 5B to 5D). There-
after, the procedure was performed using femoral
access (arterial: 7-F; venous: 9-F). First, the left
ventricle was accessed and levocardiography was
performed, displaying a massive ventricular L-R
shunt (Video 2). To probe the VSD, a coronary diag-
nostic catheter (Judkins right 4 [Cordis]; 6-F) with a
hydrophilic wire (Radifocus Guide Wire M, Terumo)
was utilized that was pushed forward into the supe-
rior vena cava. Then, the tip was externalized using a
snare technique (GooseNeck Snare EV3, Medtronic)
(Video 3), and the occluder device was advanced via
the femoral vein and implanted without any compli-
cations (Video 4). Final levocardiography showed a
notable reduction of the L-R shunt with a good final
result (Video 5). Postoperative echocardiography
documented an adequate position of the device
without any shunt flow (Video 6).
FIGURE 2 Computer Model Based on Cardiac Computed Tomography
(A) Representation of the transverse myocardial segmentation viewed from above. (B) Isometric representation of a sectional view (in the axial plane) at the level of the
septal defect of the 3-dimensional (3D) model. (C) Isometric 3D view of complete segmented heart. Red areas are the left ventricle/atrium and aorta, and blue areas
depict the right ventricle/atrium and pulmonary artery. Light gray areas depict the blood volume, dark gray represents the surrounding myocardium, which was printed
in 3D.
FIGURE 3 2-Dimensional Representation of the Matching
DICOM Image to the Segmentation
Areas marked in purple depict the myocardium. Exemplary
measurement of the size of the septal defect.
JACC: CASE REPORTS, VOL. 11, 2023 Hofmann et al
APRIL 5, 2023:101789 Interventional Treatment of Recurrent VSD Planed by 3D-Printed Reconstruction of the Heart
3

FOLLOW-UP
The patient was discharged from our department with
asignificant reduction of subjective symptoms of
dyspnea 2 days after the procedure. Twelve months
later, clinical visit and computed tomography angi-
ography showed an excellent result without any
symptoms of dyspnea or significant shunt volume.
DISCUSSION
To the best of our knowledge, this is the firstreportof
the utilization of a personalized 3D-printed model of
the heart for preprocedural planning and simulation
to obtain the best procedural outcome in treating a
case of recurrent VSD with residual patch material.
In the past decade, there have been fundamental
developments in both cardiac imaging and 3D print-
ing technology.
6
High-resolution, electrocardiog-
raphy-triggered cardiac computer tomography is a
valuable tool for probing cardiac anatomy, and the
transfer of this complex information to computer
models utilizing manual as well as artificial intelli-
gence for segmentation has led to rapid processing
and generation.
7,8
Moreover, it is possible to physi-
cally create computer-generated models by 3D print-
ing that could be used to train and plan manually.
5
For example, 3D models showed good results when
used for preprocedural planning of transcatheter
aortic valve replacement.
9,10
Currently, the procedure
is too expensive and not time-efficient enough to use
in routine clinical practice. Furthermore, the re-
sourcesaswellastheexpertisewiththetechnique
are rare. Thus, today it is reserved only for difficult
and special cases.
9
CONCLUSIONS
Our case exemplifies the use of 3D models for pre-
procedural planning of a very complex procedure to
close a recurrent VSD after surgical correction. It
should be noted that the present report is one a single
case, and the result should not be generalized.
Currently, no data from randomized controlled trials
or observational studies are available to demonstrate
the real benefit compared with conventional planning
utilizing imaging resources. However, in the future,
automated printing of 3D models could offer new
therapeutic strategies on an individual patient basis,
especially in complex cases, making interventional
therapy more personalized.
ACKNOWLEDGMENTS In accordance with COPE
guidelines, the patient gave informed consent for
publication of the case.
FIGURE 4 3D Model Printed Using Additive Printing With Elastic Synthetic Resin in a Stereolithographic 3D Printer
(A, B) Model viewed from the side and the top. (C) Ischemic ventricular septal defect from the LV side, displaying residual pericardial patch tissue. LV ¼left ventricle;
LVOT ¼left ventricular outflow tract; RV ¼right ventricle. Abbreviation as in Figure 2.
Hofmann et al JACC: CASE REPORTS, VOL. 11, 2023
Interventional Treatment of Recurrent VSD Planed by 3D-Printed Reconstruction of the Heart APRIL 5, 2023:101789
4

FUNDING SU PPORT AND A UTHOR DIS CLOSURES
Drs Dörr and Nef have received speaker honoraria from Abbott
Vascular. All other authors have reported that they have no re-
lationships relevant to the contents of this paper to disclose.
ADDRESS FOR CORRESPONDENCE: Dr Holger Nef,
Universitätsklinikum Gießen und Marburg, Klinikstraße
33, 35392 Gießen, Germany. E-mail: holger.nef@innere.
med.uni-giessen.de. Twitter: @HolgerNef.
FIGURE 5 Planning Occlusion of the Ischemic Ventricular Septal Defect Closure Within the 3D M odel
(A) View from the RV showing insufficient positioning with protrusion and incorrect apposition of the Amplatzer VSD P.I. muscular occluder.
(B) View from the RV showing the 30-mm atrial septal defect (ASD) occluder with overlap at the ventral RV wall (red line).(C) View from the
RV showing the 25-mm ASD occluder with good apposition. (D) View from the LV showing the 25-mm ASD occluder with good apposition.
Abbreviations as in Figures 2 and 4.
JACC: CASE REPORTS, VOL. 11, 2023 Hofmann et al
APRIL 5, 2023:101789 Interventional Treatment of Recurrent VSD Planed by 3D-Printed Reconstruction of the Heart
5

REFERENCES
1. Menon V, Webb JG, Hillis LD, et al. Outcome and
profile of ventricular septal rupture with cardio-
genic shock after myocardial infarction: a report
from the SHOCK trial registry. SHould we emer-
gently revascularize Occluded Coronaries in
cardiogenic shock. J Am Coll Cardiol. 2000;36:
1110–1116.
2. Crenshaw BS, Granger CB, Birnbaum Y, et al.
Risk factors, angiographic patterns, and out-
comes in patients with ventricular septal
defect complicating acute myocardial infarc-
tion. GUSTO-I (Global Utilization of Str epto-
kinase and TPA for Occluded Corona ry
Arteries) Trial Investigators. Circulation.
2000;101:27–32.
3. Neumann F-J, Sousa-Uva M, Ahlsson A, et al,
ESC Scientific Document Group. 2018 ESC/EACTS
guidelines on myocardial revascularization. Eur
Heart J. 2019;40(2):87–165.
4. Kamioka N, Lederman RJ, Greenbaum AB, et al.
Postinfarction ventricular septal defect closure.
Circ Cardiovasc Interv. 2019;12:e007788.
5. Lindquist EM, Gosnell JM, Khan SK, et al. 3D
printing in cardiology: a review of applications and
roles for advanced cardiac imaging. Ann 3D Printed
Med. 2021;4:100034.
6. Ventola CL. Medical applications for 3D print-
ing: current and projected uses. PT. 2014;39:704–
711.
7. Christensen A. Chapter 1 - an abbreviated his-
tory of medical 3D printing. In: Wake N, ed. 3D
Printing for the Radiologist. Elsevier; 2021:1–10.
https://doi.org/10.1016/C2019-0-04024-1
8. Shilo D, Emodi O, Blanc O, Noy D, Rachmiel A.
Printing the future-updates in 3D printing for
surgical applications. Rambam Maimonides Med J.
2018;9(3):e0020.
9. Jimenez Restrepo A, Chahal D, Gupta A. Road-
map to success: 3D printing in pre-procedural
planning. J Am Coll Cardiol Case Rep. 2020;2:
358–360.
10. Alasnag MA, Al-Nasser IM, Porqueddu MM,
Ahmed WH, Al-Shaibi KF. 3D model guiding
transcatheter aortic valve replacement in a patient
with aortic coarctation. J Am Coll Cardiol Case Rep.
2020;2:352–357.
KEY WORDS acute coronary syndrome,
biotechnology, complication, imaging, left
ventricle, myocardial infarction, myocardial
ischemia, ventricular septal defect,
3-dimensional printing
APPENDIX For supplemental videos,
please see the online version of this paper.
Hofmann et al JACC: CASE REPORTS, VOL. 11, 2023
Interventional Treatment of Recurrent VSD Planed by 3D-Printed Reconstruction of the Heart APRIL 5, 2023:101789
6