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Bui et al. Vessel Plus 2021;6:31 https://dx.doi.org/10.20517/2574-1209.2021.97 Page 3 of 12

[21]
Hoashi et al. found the greatest utility of 3D cardiac models in the education of young surgeons who are
inexperienced in biventricular repair. The team produced twenty 3D printed heart models with varying
congenital heart defects. They concluded that the models provided sufficient detail for the surgeon who had
no prior experience in biventricular repair by assisting in the identification of a surgical approach and
creating a potential surgical simulation. Patients who underwent surgeries did not experience complications
[21]
during the surgery, and there was no mortality observed in the one or two years follow-up appointments .
Overall, 3D cardiac models is a great educational tool as it lessens the learning curve for surgical trainees,
provide a platform for presurgical simulation, and exposure to rare cardiac lesions [18,19] .

3D printed cardiac models are not only useful in the planning and surgical repair of cardiac defects. For
patients with aortic stenosis, patient-specific 3D printed aortic roots can be used to determine if they are
suitable for a transcatheter aortic valve replacement. These aortic root models can undergo physiological
testing so that only patients with lower risk of paravalvular leaks, which is associated with a lower late
mortality, proceed with the procedure. Cardiac models are also helpful in delineating structures of the left
ventricle which is imperative for a patient with hypertrophic cardiomyopathy undergoing septal
[17]
myomectomy . In patients with heart failure requiring a ventricular assist device (VAD), a cardiac model
can be used as a guide to showcase anatomical challenges that can make VAD and cannula placement
challenging [17,18] .

Three-dimensional cardiac models can be very useful in surgical pre-planning and biventricular repair in
complex heterotaxy patients [22,23] . A 3D cardiac model was utilized at our institution for a five-month-old
patient with heterotaxy syndrome consisting of atrial situs ambiguous with a common atrium and ipsilateral
pulmonary veins, D-looped ventricles, normally related great arteries (ADS), interrupted inferior vena cava
with hemi-azygous continuation to the left superior vena cava (SVC) draining into the left and anterior
aspect of the common atrium, hepatic veins draining to the right side of the common atrium, a partial AV
[22]
canal, small anterior muscular VSD . With the aid of a cardiac model [Figures 1 and 2], the cardiothoracic
surgeon concluded that intracardiac repair using the Mustard method was not possible due to limited space.
The decision was then made to proceed with complex biventricular repair using a modified Warden
procedure by creating a baffle starting from the base of the left SVC, incorporating the left and right atrial
appendages, and connecting to the right atrium.

Besides benefits in the operating theatre and surgical education, 3D printed heart models can also
strengthen relationships as it improves communication among medical providers, and between patient and
physician. Cardiologists can utilize 3D printed models to educate patients and their guardians on the
progress of their conditions while looking at the pathological region within the heart. Parents of congenital
heart disease patients enthusiastically appreciated their encounters with physicians after 3D printed models
of the patients’ hearts were used [19,24] .

Limitations of 3D printing
Although 3D printed models can accurately depict organ pathology and provide multidirectional views,
they still face limitations in areas such as cost, processing time, technicality, etc. The main cost involved is in
the initial set-up which can range from USD $5000 to 600,000 for a 3D printer. In addition, a segmentation
software can cost up to $15,000 for an annual subscription . However, with the initial set-up complete, the
[17]
final materials cost is more affordable and can range from less than a hundred to thousands of dollars
depending on the complexity of the model, size of the heart, and materials used [25-29] . Despite the high set-up
cost of 3D printing, it is still significantly less than the financial and emotional burden on a patient who
might require multiple surgeries if the surgery did not go successfully due to the lack of 3D visualization.