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Modeling Fetal Cardiac Anomalies From Prenatal Echocardiography With 3-Dimensional Printing and 4-Dimensional Flow Magnetic Resonance Imaging

2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 9 Linguagem: Inglês

10.1161/circimaging.118.007705

1942-0080

Katrina L. Falk, Huairen Zhou, Barbara Trampe, Timothy Heiser, Shardha Srinivasan, J. Igor Iruretagoyena, Alejandro Roldán‐Alzate,

Congenital Diaphragmatic Hernia Studies

HomeCirculation: Cardiovascular ImagingVol. 11, No. 9Modeling Fetal Cardiac Anomalies From Prenatal Echocardiography With 3-Dimensional Printing and 4-Dimensional Flow Magnetic Resonance Imaging Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBModeling Fetal Cardiac Anomalies From Prenatal Echocardiography With 3-Dimensional Printing and 4-Dimensional Flow Magnetic Resonance Imaging Katrina L. Falk, BS, Huairen Zhou, BS, Barbara Trampe, RN, RDMS, Timothy Heiser, RDMS, Shardha Srinivasan, MD, J. Igor Iruretagoyena, MD and Alejandro Roldán-Alzate, PhD Katrina L. FalkKatrina L. Falk Department of Biomedical Engineering, University of Wisconsin-Madison (K.L.F., A.R.-A.) , Huairen ZhouHuairen Zhou Department of Mechanical Engineering, University of Wisconsin-Madison (H.Z., A.R.-A.) , Barbara TrampeBarbara Trampe Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin-Madison (B.T., T.H., J.I.I.) , Timothy HeiserTimothy Heiser Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin-Madison (B.T., T.H., J.I.I.) , Shardha SrinivasanShardha Srinivasan Department of Biomedical Engineering, University of Wisconsin-Madison (K.L.F., A.R.-A.) , J. Igor IruretagoyenaJ. Igor Iruretagoyena Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin-Madison (B.T., T.H., J.I.I.) and Alejandro Roldán-AlzateAlejandro Roldán-Alzate Alejandro Roldán-Alzate at E-mail Address: [email protected], PhD, Department of Radiology, University of Wisconsin-Madison, WIMR 2476, 1111 Highland Ave, Madison, WI 53705. Department of Biomedical Engineering, University of Wisconsin-Madison (K.L.F., A.R.-A.) Department of Mechanical Engineering, University of Wisconsin-Madison (H.Z., A.R.-A.) Department of Radiology, University of Wisconsin-Madison (A.R.-A.) Originally published17 Sep 2018https://doi.org/10.1161/CIRCIMAGING.118.007705Circulation: Cardiovascular Imaging. 2018;11:e007705Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 17, 2018: Previous Version of Record Fetal cardiac anomalies are among the hardest anomalies to characterize in utero and range from simple cardiac lesions to lesions involving complex morphological derangements and associated flow abnormalities. Multifactorial in origin, some of these defects have a clear genetic basis; however, it is well recognized that some are affected by flow patterns through the developing heart and evolve throughout gestation.1 Fetal echocardiography is the cornerstone in clinical diagnosis and in trained hands has achieved a high degree of diagnostic accuracy. However, it is challenging to visualize how subtle differences in anatomic relationships impact intracardiac flow patterns. In vitro 4-dimensional (4D) flow magnetic resonance imaging (MRI), a technique that combines patient-specific 3D printed geometries with MRI, has been successful to model specific hemodynamic states in an effort to improve surgical techniques, as well as study system efficiency.2,3 Most patient-specific 3D printed models are derived from MRI or computed tomography data sets, with only 1 account of printing from an adult echocardiogram.4 We present a novel methodology that creates a patient-specific, 3D printed fetal heart model derived from a fetal echocardiogram, which is integrated with 4D flow MRI and on further validation, can be used to analyze intracardiac flow profiles in vitro.The data that support the findings of this study are available from the corresponding author on reasonable request. Two fetal echocardiograms, 1 normal developing fetal heart at 30 weeks gestation, and 1 with hypoplastic left heart syndrome at 24 weeks, were analyzed with institutional review board approval and written consent was not required. Patients underwent routine ultrasound examinations (VolusionE10, GE Healthcare, Waukesha, WI) according to their normal pregnancy protocol. Ultrasound data were segmented using Mimics and 3-Matic (Materialize, Leuven, Belgium) to make virtual, real size, 3D models, which were 3D printed (Form2, Formlabs Inc, Somerville, MA; Figure [A and B]).Download figureDownload PowerPointFigure. Fetal heart modeling with 3D printing and 4D flow MRI.A, Virtual fetal heart model (scale in cm) obtained from a fetal echocardiogram showing the anterior view of the normal (i) and abnormal heart (ii). The posterior view of the abnormal (ii) shows the hypoplastic left heart syndrome. B, Three-dimensional (3D) printed flow models of the normal (i) and abnormal (ii) fetal heart for 4D flow magnetic resonance imaging (MRI). Purposeful alteration of the virtual 3D models was done to increase wall size and add barbed connectors to create a flow model for 4D flow MRI. C, Visualization of blood flow through velocity streamlines (m/s) from 4D flow MRI of the normal heart model. Fluid accelerates as it leaves the inferior vena cava (IVC) and forms a vortex of decelerating fluid in part of the right atrium (RA), consistent with well-understood flow patterns (bottom inset). A preferential flow path from the superior vena cava (SVC) and IVC to the pulmonary artery (PA) inlet and through the ductus arteriosus (DA) is observed and denoted by the dashed line. The upper inset shows the top view where the aorta (A) ascends and descends over the PA. Velocity increases in the main PA and before the PA bifurcation (white arrow), consistent with the PA anatomy. D, Visualization of blood flow through velocity streamlines (m/s) from 4D flow MRI of the fetal heart with hypoplastic left heart syndrome. Streamlines are less defined and there is a prominent low-velocity vortex seen in the mid-cavity region of the right ventricle (RV; inset). Velocity increases in the main PA and before the PA bifurcation (white arrow), consistent with the normal flow acceleration across the pulmonary valve. Overall, higher velocities correspond with the characteristics of hypoplastic left heart syndrome. E and F, Results from computational fluid dynamic simulations of the normal (E) and abnormal (F) fetal heart models. Boundary conditions were based on the average flow distributions from MRI and created similar velocity values. LPA indicates left pulmonary artery; LPV, left pulmonary vein; RPA, right pulmonary artery; and RPV, right pulmonary vein.Both models were connected to a positive displacement pulsatile pump at 1 L/min (BDC PC-1100, BDC Laboratories, Wheat Ridge, CO) with inlets (inferior vena cava and superior vena cava, and pulmonary veins), outlets (aorta and pulmonary arteries) and proper resistances to represent fetal circulation. Both models were imaged using a clinical 1.5T MRI scanner (GE Healthcare, Waukesha, WI). Flows were visualized and quantified using EnSight (CIE, Apex, NC). Computational fluid dynamics simulations were performed to predict the intracardiac flow patterns and compare with in vitro results.Cardiac segmentation from fetal echocardiograms was successful, and patient-specific 3D models of the atria, ventricles, and outflow tracts were created allowing easy volume manipulation and measurements of the patient-specific 3D models (Figure [A]). Characteristics of hypoplastic left heart syndrome, including an under-developed ventricle and hypoplastic aorta, can be visualized in the abnormal case of Figure [A]. Purposeful alteration of the virtual model was done to increase the wall size and add barbed connectors to create an anatomically realistic, 3D printed (resolution=0.025 mm) flow model for 4D flow MRI (Figure [B]). Volumetric flow through each vessel was measured in mL/min by placing a plane through each cross section and was consistent with conservation of mass. Unique flow patterns were seen in both models and agree with previously understood circulation patterns, such as the preferential flow of superior vena cava and systemic venous inferior vena cava blood across the tricuspid valve into the right ventricle (Figure [C and D]).5 Velocities, vortices, and complex distributions were visualized using 4D flow MRI on both models (Figure [C and D]). In this preliminary study, good agreement in velocity patterns was found between computational fluid dynamics simulations and 4D flow MRI (Figure [E and F]). We plan, as part of future studies to validate this technique by including the ductus venosus to reproduce normal circulation and study the impact of abnormal connections on intracardiac flow patterns. Assuming all resources (ultrasound, 3D printer, MRI scanner, and pump) are available, this process could be completed within 2 weeks, making it compatible with the current standard of care follow-up of the mother. Although at an early stage, 2 gestational ages were used to show the potential applicability of this technique to multiple cardiac anomalies.Although a rigid and open-heart model, this preliminary technique introduces a novel way of using previously studied modeling techniques to create a patient-specific, virtual and physical 3D model for intracardiac flow pattern estimation at a low manufacturing cost and no extra patient time. Once the 3D models are verified by inclusion of the ductus venosus, this technique will be valuable for parents to understand complex cardiac anomalies by viewing it in a physical, 3D format. On further validation, the future value of this technique is in providing an in vitro patient-specific model to study alternations in flow dynamics in complex heart defects and possibly aid in our understanding of their evolution. It also has potential benefit in parental counseling in some complex heart defects, such as heterotaxy or forms of double right ventricle, where intracardiac streaming is important in surgical decisions. Introducing 3D modeling and 4D flow MRI into the realm of fetal life has potential future benefits to help improve the understanding of fetal cardiac anomalies.Sources of FundingThis work was funded by the National Institutes of Health Grant, 4K12-DK100022-04 (Dr Roldán-Alzate).DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circimagingKatrina L. Ruedinger, BS, Department of Biomedical Engineering, University of Wisconsin-Madison, WIMR 2476, 1111 Highland Ave, Madison, WI 53705, Email [email protected]eduAlejandro Roldán-Alzate at [email protected]edu, PhD, Department of Radiology, University of Wisconsin-Madison, WIMR 2476, 1111 Highland Ave, Madison, WI 53705.REFERENCES1. Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J; American Heart Association Adults With Congenital Heart Disease Joint Committee of the Council on Cardiovascular Disease in the Young and Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular and Stroke Nursing. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association.Circulation. 2014; 129:2183–2242. doi: 10.1161/01.cir.0000437597.44550.5dLinkGoogle Scholar2. Rutkowski DR, Reeder SB, Fernandez LA, Roldán-Alzate A. Surgical planning for living donor liver transplant using 4D flow MRI, computational fluid dynamics and in vitro experiments.Comput Methods Biomech Biomed Eng Imaging Vis. 2018; 6(5):545–555. https://www.ncbi.nlm.nih.gov/pubmed/30094106. Accessed September 7, 2018. doi: 10.1080/21681163.2017.1278619CrossrefGoogle Scholar3. Roldán-Alzate A, Francois CJ, Wieben O, Reeder SB. Emerging applications of abdominal 4D flow MRI.AJR Am J Roentgenol. 2016; 207:58–66. doi: 10.2214/AJR.15.15995CrossrefMedlineGoogle Scholar4. Samuel BP, Pinto C, Pietila T, Vettukattil JJ. Ultrasound-derived three-dimensional printing in congenital heart disease.J Digit Imaging. 2015; 28:459–461. doi: 10.1007/s10278-014-9761-5CrossrefMedlineGoogle Scholar5. Rudolph AM, Heymann MA. The circulation of the fetus in utero.Circ Res. 1967; 21:163 LP–184 LP.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By van Amerom J, Goolaub D, Schrauben E, Sun L, Macgowan C and Seed M (2022) Fetal cardiovascular blood flow MRI: techniques and applications, The British Journal of Radiology, 10.1259/bjr.20211096 Meyer-Szary J, Luis M, Mikulski S, Patel A, Schulz F, Tretiakow D, Fercho J, Jaguszewska K, Frankiewicz M, Pawłowska E, Targoński R, Szarpak Ł, Dądela K, Sabiniewicz R and Kwiatkowska J (2022) The Role of 3D Printing in Planning Complex Medical Procedures and Training of Medical Professionals—Cross-Sectional Multispecialty Review, International Journal of Environmental Research and Public Health, 10.3390/ijerph19063331, 19:6, (3331) Yu C, Che Y, Sun G, Zhao X, Liu B and Khalaf O (2022) Research on Diagnosis Architecture of Cardiovascular Diseases Based on Multimedical Images, Computational and Mathematical Methods in Medicine, 10.1155/2022/9123332, 2022, (1-8), Online publication date: 9-Feb-2022. 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September 2018Vol 11, Issue 9 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.007705PMID: 30354680 Originally publishedSeptember 17, 2018 Keywordsechocardiographyfetal heartpregnancymagnetic resonance imaginghemodynamicsPDF download Advertisement SubjectsCongenital Heart DiseaseHemodynamicsMagnetic Resonance Imaging (MRI)PregnancyUltrasound