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A Workflow for Three-Dimensional Printing with Echocardiographic Data

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A Workflow for Three-Dimensional Printing with Echocardiographic Data Making three-dimensional echocardiography more tangible: a workflow for three-dimensional printing with echocardiographic data The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Mashari, Azad, Mario Montealegre-Gallegos, Ziyad Knio, Lu Yeh, Jelliffe Jeganathan, Robina Matyal, Kamal R Khabbaz, and Feroze Mahmood. 2016. “Making three-dimensional echocardiography more tangible: a workflow for three-dimensional printing with echocardiographic data.” Echo Research and Practice 3 (4): R57-R64. doi:10.1530/ERP-16-0036. http://dx.doi.org/10.1530/ ERP-16-0036. Published Version doi:10.1530/ERP-16-0036 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32071935 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA ID: XX-XXXX; XXX 2016 10.1530/ERP-16-0036 A Mashari and others Workflow for 3D printing from ID: 16-0036; December 2016 echocardiographic data DOI: 10.1530/ERP-16-0036 REVIEW Making three-dimensional echocardiography more tangible: a workflow for three-dimensional printing with echocardiographic data Azad Mashari MD1,2, Mario Montealegre-Gallegos MD2, Ziyad Knio BS3, Lu Yeh MD2,4, Jelliffe Jeganathan MBBS2, Robina Matyal MD2, Kamal R Khabbaz MD3 and Feroze Mahmood MD2 1Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada 2Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Correspondence Harvard Medical School, Boston, Massachusetts, USA should be addressed 3Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, to M Montealegre-Gallegos Boston, Massachusetts, USA Email 4Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, [email protected]. The Netherlands edu Abstract Three-dimensional (3D) printing is a rapidly evolving technology with several potential Key Words applications in the diagnosis and management of cardiac disease. Recently, 3D printing f rapid prototyping (i.e. rapid prototyping) derived from 3D transesophageal echocardiography (TEE) has f 3D printing become possible. Due to the multiple steps involved and the specific equipment required f transesophageal for each step, it might be difficult to start implementing echocardiography-derived echocardiography 3D printing in a clinical setting. In this review, we provide an overview of this process, f patient-specific models including its logistics and organization of tools and materials, 3D TEE image acquisition strategies, data export, format conversion, segmentation, and printing. Generation of patient-specific models of cardiac anatomy from echocardiographic data is a feasible, practical application of 3D printing technology. Introduction Imaging techniques such as computerized tomography of procedure suitability, real-time guidance, and (CT), magnetic resonance imaging (MRI), and post-procedure assessment (5). transesophageal echocardiography (TEE) are commonly Currently, 3D images are analyzed and evaluated used for diagnosis, monitoring, and decision-making on flat displays, on which different shades, opacity, and in patients with cardiovascular disease (1, 2). In cardiac color tones are used to create a perception of depth. surgery, TEE is the imaging modality of choice due to While these images provide superior spatial orientation its portability and availability at the point-of-care, and compared to traditional 2D TEE images, they are limited because it is capable of generating high-quality two- and by parallax error (3). Therefore, accurate measurements three-dimensional (2D, 3D) images with high temporal require generation of 2D slices through multi-planar and spatial resolution (3, 4). Recently, there has been an reconstruction. While 3D images have been helpful in increase in use of 3D TEE as an adjunct for percutaneous surgical planning, they lack the haptic feel and true cardiac interventions. Intraoperative TEE-derived 3D perspective that would be obtained with an actual, information has significant value in the evaluation patient-specific physical model. This work is licensed under a Creative Commons © 2016 The authors www.echorespract.com Attribution-NonCommercial 4.0 International Published by Bioscientifica Ltd License. A Mashari and others Workflow for 3D printing from ID: 16-0036; December 2016 echocardiographic data DOI: 10.1530/ERP-16-0036 Rapid prototyping (i.e. 3D printing) has several room, and other factors such as magnetic interference and potential applications in cardiac surgery (6, 7, 8, 9, 10, 11). use of ionizing radiation. Traditionally, visual assessment of the heart valves during Recently, echocardiographic data have been used to open-heart surgery has been performed on an empty create patient-specific 3D-printed anatomical models and paralyzed heart. Furthermore, in minimally invasive of intracardiac structures (12, 14, 15, 16). The ‘image to surgery and percutaneous valve interventions, there is print’ time for this process is currently on the order of limited or no direct valve exposure during the procedure. hours for most structures of interest. However, with the Therefore, availability of a tangible high-fidelity 3D rapid advances currently taking place in this field, this model of a valve prior to intervention could provide an technology will likely become ‘point-of-care’ in the near opportunity for ‘ex vivo’ valve analysis. In addition, such future (17, 18). There are multiple software, hardware, models could potentially be used for procedural training, and material choices for echocardiography-derived 3D to aid in communication with patients or among members printing, ranging from low-cost desktop systems to of the surgical team, and for designing patient-specific industrial-level ones. procedures and prostheses. With the rapid development Given that 3D printing from echocardiographic data of 3D printing technology and the growing range of is relatively novel and didactic materials are sparse and available materials, it is now possible to print models technical, choosing appropriate hardware and software that mimic mechanical properties of certain tissues and equipment can be difficult and confusing. Therefore, that could be sterilized and potentially implanted. With drawing upon our experience we have described the improvements in technology, clinical applications of 3D workflow for 3D printing of cardiac anatomical structures printing are likely to expand significantly in the near from 3D TEE data. future (12). Patient-specific models of anatomical structures such as the skull or aorta can be generated using 3D printing (8, 13). Workflow The majority of 3D printing in medicine to date has been The workflow for echocardiography-based 3D printing based on CT and MRI data. The high spatial resolution, can be broadly divided as follows (Fig. 1): relatively high signal-to-noise ratio, and Digital Imaging and Communications in Medicine (DICOM) standardization of a) Logistics data formats for these modalities simplify their processing b) Echocardiographic image acquisition (seconds to into printable models. However, CT and MRI’s use for point- minutes) of-care imaging in cardiac procedures is limited by their low c) Data export (minutes) temporal resolution, limited accessibility in the operating d) Format conversion (minutes) Figure 1 Summarized workflow for 3D printing of a 3D TEE data set of a mitral valve after a MitraClip procedure. Examples of file formats used are included where applicable. From left to right: After export from the ultrasound system, the data set is converted to the Philips Cartesian DICOM format (first panel). Using segmentation software the voxels in the region of interest are labeled, creating a ‘solid’ voxel model (second panel). A triangular surface mesh model is generated based on the voxel model (third panel). The mesh model is processed by the slicing software, generating a printer code, which directs the printing of the final model (fourth panel). (File formats: NIFTI, Neuroimaging Informatics Technology Initiative; NRRD, Nearly Raw Raster Data; STL, Stereolithography; PLY, Polygon; OBJ, Wavefront Object.) www.echorespract.com R58 A Mashari and others Workflow for 3D printing from ID: 16-0036; December 2016 echocardiographic data DOI: 10.1530/ERP-16-0036 e) Segmentation (minutes to few hours) real spatial resolution of the printed model is ultimately f) Generation and refinement of a mesh surface model limited by the resolution of the original data set, which is (several minutes) significantly lower than that of most desktop 3D printers. g) Printing (minutes to hours) Therefore, while higher resolution printers can potentially print more aesthetically appealing models, these models are not more accurate in their representation of the underlying imaging data. Logistics Echocardiography-derived 3D printing is dependent on the acquisition of high-quality 3D data sets of intracardiac Echocardiographic image acquisition anatomical structures and their subsequent conversion to printable formats. Besides a 3D printer, accomplishing With the exception of 3D color flow Doppler, all this task requires a trained echocardiographer, a 3D 3D imaging modes can be currently
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