Case report
Patient-specific 3D printing simulation to guide complex coronary intervention
Intervenção coronária complexa guiada por simulação específica com impressão 3D
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array:25 [ "pii" => "S0870255117309459" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.02.007" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "1201" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2018" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2018;37:541.e1-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2406 "formatos" => array:3 [ "EPUB" => 107 "HTML" => 1939 "PDF" => 360 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S2174204918302083" "issn" => "21742049" "doi" => "10.1016/j.repce.2018.02.018" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "1201" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2018;37:541.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1340 "formatos" => array:3 [ "EPUB" => 131 "HTML" => 981 "PDF" => 228 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Patient-specific 3D printing simulation to guide complex coronary intervention" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "541.e1" "paginaFinal" => "541.e5" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Intervenção coronária complexa guiada por simulação específica com impressão 3D" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1368 "Ancho" => 2457 "Tamanyo" => 272852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The steps for creating a patient-specific 3D coronary model for simulation are depicted. They include segmentation of the coronary angiography in order to create a 3D patient-specific digital model, and post-processing to obtain a flexible and transparent patient-specific physical model that could be connected to the custom interventional cardiology simulator SimulHeart<span class="elsevierStyleSup">®</span>. The images on the bottom show the ostial circumflex stenosis model on visual inspection (left) and the post-intervention result after stent placement (right).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel Oliveira-Santos, Eduardo Oliveira Santos, Ana Vera Marinho, Luís Leite, Jorge Guardado, Vítor Matos, Guilherme Mariano Pego, João Silva Marques" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Manuel" "apellidos" => "Oliveira-Santos" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Oliveira Santos" ] 2 => array:2 [ "nombre" => "Ana Vera" "apellidos" => "Marinho" ] 3 => array:2 [ "nombre" => "Luís" "apellidos" => "Leite" ] 4 => array:2 [ "nombre" => "Jorge" "apellidos" => "Guardado" ] 5 => array:2 [ "nombre" => "Vítor" "apellidos" => "Matos" ] 6 => array:2 [ "nombre" => "Guilherme Mariano" "apellidos" => "Pego" ] 7 => array:2 [ "nombre" => "João Silva" "apellidos" => "Marques" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117309459" "doi" => "10.1016/j.repc.2018.02.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117309459?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918302083?idApp=UINPBA00004E" "url" => "/21742049/0000003700000006/v3_201807150625/S2174204918302083/v3_201807150625/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S0870255117300215" "issn" => "08702551" "doi" => "10.1016/j.repc.2017.03.013" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "1203" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2018;37:543-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1673 "formatos" => array:3 [ "EPUB" => 140 "HTML" => 1167 "PDF" => 366 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>" "titulo" => "Intimal sarcoma of the left atrium – A rare form of mitral valve obstruction" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "543" "paginaFinal" => "544" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Sarcoma da íntima da aurícula esquerda – uma forma rara de obstrução valvular mitral" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1419 "Ancho" => 1897 "Tamanyo" => 515893 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Panel A</span>: Apical four-chamber view showing a dilated left atrium with a large left atrial mass. <span class="elsevierStyleBold">Panel B</span>: Transmitral gradient recorded from apical approach using continuous wave Doppler across the mitral valve. A mean value of 8 mmHg and a peak of 25 mmHg were observed. <span class="elsevierStyleBold">Panel C</span>: Off-axis transesophageal image showing multilobulated mass attached to left atrial posterolateral wall. <span class="elsevierStyleBold">Panel D</span>: 12° Right Anterior Oblique, 15° caudal projection showing high vascularization of the tumor through all three major vascular beds. <span class="elsevierStyleBold">Panel E</span>: 4-chamber MRI T1-weighted image showing mass isointensity. <span class="elsevierStyleBold">Panel F</span>: 4-chamber MRI T2-weighted image depicting mass hyperintensity. <span class="elsevierStyleBold">Panel G</span>: 4-chamber MRI contrast enhanced image revealing heterogeneous uptake after gadolinium contrast administration, with low signal intensity in a central area. <span class="elsevierStyleBold">Panel H</span>: Macroscopic view of the excised tumor. <span class="elsevierStyleBold">Panel I</span>: Histopathology: (H&E, ×100) malignant neoplasm, predominantly undifferentiated, with prominent pleomorphism, with fusiform and epithelioid cells; mitotic activity and necrosis that was easy to find. <span class="elsevierStyleBold">Panel J</span>: (vimentin, ×100) – expression of vimentin in malignant cells (fusiform and epithelioid). <span class="elsevierStyleBold">Panel K</span>: (MDM2, ×100) – nuclear multifocal expression of MDM2 in malignant cells; all other markers negative (SMA, desmin, CD31, CD34, S100, FVIII, CK8/18, HMB45). <span class="elsevierStyleBold">Panel L</span>: Post-operative CT showing tumor relapse, with extensive growth into left atrium and pulmonary vein invasion.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT: computed tomography; MRI: magnetic resonance imaging.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Glória Abreu, Alberto Salgado, Nuno Bettencourt, Nuno Salomé, João Ferreira, Susana Guimarães" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Glória" "apellidos" => "Abreu" ] 1 => array:2 [ "nombre" => "Alberto" "apellidos" => "Salgado" ] 2 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Salomé" ] 4 => array:2 [ "nombre" => "João" "apellidos" => "Ferreira" ] 5 => array:2 [ "nombre" => "Susana" "apellidos" => "Guimarães" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204918302095" "doi" => "10.1016/j.repce.2017.03.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918302095?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117300215?idApp=UINPBA00004E" "url" => "/08702551/0000003700000006/v2_201806270452/S0870255117300215/v2_201806270452/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255116303286" "issn" => "08702551" "doi" => "10.1016/j.repc.2017.04.008" "estado" => "S300" "fechaPublicacion" => "2018-06-01" "aid" => "1204" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2018;37:539.e1-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2166 "formatos" => array:3 [ "EPUB" => 120 "HTML" => 1711 "PDF" => 335 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Left atrium and pulmonary artery compression due to aortic aneurysm causing heart failure symptoms" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "539.e1" "paginaFinal" => "539.e2" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Compressão do átrio esquerdo e artéria pulmonar por um aneurisma da aorta causando sintomas de insuficiência cardíaca" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1189 "Ancho" => 1584 "Tamanyo" => 131875 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography angiography with contrast.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">DAo: descending thoracic aorta; LA: left atrium; PAT: pulmonary artery truncus; TAA: thoracic aortic aneurysm.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio José Lagoeiro Jorge, Wolney de Andrade Martins, Victor M. Moutinho, Juliano M. Rezende, Patricia Y. Alves, Humberto Villacorta, Pedro F. Silveira, Antonio A. Couto" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Antonio José Lagoeiro" "apellidos" => "Jorge" ] 1 => array:2 [ "nombre" => "Wolney de Andrade" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Victor M." "apellidos" => "Moutinho" ] 3 => array:2 [ "nombre" => "Juliano M." "apellidos" => "Rezende" ] 4 => array:2 [ "nombre" => "Patricia Y." "apellidos" => "Alves" ] 5 => array:2 [ "nombre" => "Humberto" "apellidos" => "Villacorta" ] 6 => array:2 [ "nombre" => "Pedro F." "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Antonio A." "apellidos" => "Couto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204918302071" "doi" => "10.1016/j.repce.2017.04.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918302071?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303286?idApp=UINPBA00004E" "url" => "/08702551/0000003700000006/v2_201806270452/S0870255116303286/v2_201806270452/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Patient-specific 3D printing simulation to guide complex coronary intervention" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "541.e1" "paginaFinal" => "541.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manuel Oliveira-Santos, Eduardo Oliveira Santos, Ana Vera Marinho, Luís Leite, Jorge Guardado, Vítor Matos, Guilherme Mariano Pego, João Silva Marques" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Manuel" "apellidos" => "Oliveira-Santos" "email" => array:1 [ 0 => "oliveirasantos@uc.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Oliveira Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ana Vera" "apellidos" => "Marinho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Luís" "apellidos" => "Leite" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Jorge" "apellidos" => "Guardado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Vítor" "apellidos" => "Matos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Guilherme Mariano" "apellidos" => "Pego" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "João Silva" "apellidos" => "Marques" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia A, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Engenharia Mecânica, Faculdade de Ciências e Tecnologia da Universidade de Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Intervenção coronária complexa guiada por simulação específica com impressão 3D" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1698 "Ancho" => 3167 "Tamanyo" => 433902 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Side-by-side display of matched angiographic appearance (Panel A) and OCT imaging (Panel B) of patient-specific simulated procedure and actual procedure for comparative purposes. (Panel A) Angiographic images depicting the sequential procedural steps from diagnosis to final surgical result. (Panel B) OCT still frames of minimal luminal area before intervention and the final result after stent implantation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 85-year-old female came in to the outpatient clinic for a follow-up visit complaining of a two-month history of typical chest pain on exertion (grade II-III according to the Canadian Cardiovascular Society classification) and progressive dyspnea. Her cardiovascular risk factors included hypertension, dyslipidemia and obesity. Past medical history was significant for coronary artery disease with hospitalization for unstable angina three years before. At that time, ejection fraction was normal and coronary angiography showed mild distal left main disease and severe diffuse stenosis of the right coronary artery (RCA). Four drug-eluting stents (DES) were implanted in the RCA with good acute angiographic result. After hospital discharge she was doing well, without any symptoms. Treatment included acetylsalicylic acid 100 mg, lisinopril 20 mg, nebivolol 5 mg and pitavastatin 2 mg daily. A nitroglycerin transdermal patch was added to her usual therapeutic regimen and she was scheduled for invasive stratification. At coronary angiography, mild diffuse restenosis of the RCA stents was found. An intermediate lesion was detected in the distal left main (LM) coronary artery affecting the circumflex (Cx) ostium. There was also severe calcification of the left anterior descending (LAD) artery with intermediate lesions in the proximal and mid segments. We proceeded to functionally evaluate the patient with a Verrata<span class="elsevierStyleSup">®</span> pressure guide wire (Philips Volcano, USA), yielding an instantaneous wave-free ratio (iFR<span class="elsevierStyleSup">®</span>) of 0.79 in the mid-LAD and 0.91 in the proximal Cx. Pullback iFR<span class="elsevierStyleSup">®</span> analysis from the LAD showed that the only significant step was in the proximal LAD. Therefore, we decided to perform focal percutaneous coronary intervention (PCI) of that lesion. With a protection wire in the Cx, and following pre-dilation of the LAD with a scoring balloon, a DES was implanted in the proximal LAD (2.75×22 mm). The procedure was complicated by distal LM dissection propagating to the Cx, probably induced by deep engagement of the extra backup guiding catheter. The patient was hypotensive, but flow was restored after kissing balloon dilation in the distal LM bifurcation. After that, we used a two-stent mini-crush technique considering Cx as a side branch using a 3.5×18 mm DES and stenting LAD to LM using a 3.5×30 mm DES overlapping the other LAD stent. Kissing balloon inflation was followed by the proximal optimization technique of LM with a 5-mm balloon. The LAD to LM procedure was guided by intravascular ultrasound (IVUS) imaging. There was good stent expansion and apposition on IVUS, as well as good angiographic result. Furthermore, the final iFR on the LAD distal to stents was 0.91. The patient remained stable during hospital stay and was discharged with double antiplatelet therapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After four months, the patient presented with recurrent angina on exertion. Therefore, we performed a coronary angiography, which showed good result of the previous PCI of the LM to the LAD and RCA, but there was a critical, focal, in-stent restenosis of the ostial Cx. At that point, we decided to stage the procedure in order to plan the treatment strategy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As our group has experience in cardiac three-dimensional (3D) printing and simulation, we decided to test the treatment strategy for this complex PCI beforehand with the use of a 3D patient-specific simulator. Briefly, we used two-dimensional angiography data to render a 3D volume depicting the proximal left coronary artery using CAAS QCA-3D software (Pie Medical Imaging BV, the Netherlands) and digitally added parts to the model in order to connect it to the simulator (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The coronary anatomy was then printed in 3D using a stereolithography printer<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> in order to obtain a final patient-specific coronary artery model made of custom hybrid flexible material, with a dual-layered design and filled with fluid. Finally, we connected the coronary 3D-model to our custom-made interventional cardiology simulator, the SimulHeart<span class="elsevierStyleSup">®</span> (Coimbra, Portugal). As a brief summary, the SimulHeart<span class="elsevierStyleSup">®</span> is a realistic interventional cardiology simulator to be used in standard catheterization laboratories. Its main features include 3D-printed vascular anatomy, as well as radial and femoral access sites that enable the use of actual diagnostic and interventional devices with realistic haptics feedback (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient-specific PCI simulation was guided by optical coherence tomography (OCT) imaging, using a Dragonfly<span class="elsevierStyleSup">®</span> catheter (Abbott, Chicago, Illinois, USA). The right radial access was used to engage the left main with a 6 Fr extra backup guiding catheter. The Cx and LAD were wired and standard sized measurements for landing zones were obtained via OCT. Then, the ostial Cx stenosis was pre-dilated with 2.5- and 3.0-mm balloons, followed by the deployment of a 3.5×9-mm DES in the Cx ostium with slight protrusion to the left main stem. Then kissing balloon inflation was used to better shape the carina. Final OCT images showed good stent expansion with a small number of struts protruding to the LM, which was considered a good result for the predefined primary treatment strategy. The angiographic and OCT images of the simulated procedure are depicted in the left-hand boxes in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>. Also, at the right bottom part of <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>, the result of stent implantation can be seen by directly inspecting the transparent, flexible patient-specific 3D print.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The following day, we performed the actual procedure on the patient, keeping in mind the planned steps from the simulation. However, the right radial pulse was absent and, therefore, we used the right femoral arterial access. OCT imaging showed that the mechanism of restenosis was stent under-expansion at the Cx ostium where there was significant plaque burden that may have had limited expansion previously. Therefore, we considered that another stent was needed to reshape the vessel and minimize the recurrence of restenosis. We used a similar selection of interventional material and carried out the same sequence of steps to perform this PCI as tested the day before, achieving a good result both angiographically (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, Panel A) and on OCT imaging (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, Panel B). The procedure was uneventful and the patient was discharged the next day. <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> compares the simulation and actual procedures. The parallelism in angiographic outcomes and also the similarities in luminal gain in OCT are noteworthy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Simulation has evolved as a learning tool and has been shown to be effective for teaching both novice and experienced learners. Interventional cardiology learning curves and the volume-outcome relationship suggest that simulation may be used to potentially improve clinical results. However, several hurdles prevented it from being widely adopted in the past. Nowadays, 3D printing is emerging<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> and may be a game-changing technology to replicate vascular anatomy and enable simulation experiences.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In particular, the exciting field of patient-specific simulation is in the early development phase, mainly in the surgical training context. A recent systematic review on this matter confirms the feasibility of patient-specific simulators and the authors hypothesize that in the future it may be able to support training of higher-level competencies. By testing a patient-specific case, the interventionist and his team could familiarize themselves with the case, try different approaches, identify potential risks, reduce radiation dose and optimize tool selection.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> A trial is currently underway for the assessment of patient-specific simulators for endovascular aneurysm repair training (<a id="intr0005" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT02372214">NCT02372214</a>). However, there are few reports on patient-specific simulations for vascular percutaneous intervention. As an example, carotid artery stenting can be tested in a virtual reality simulation with a high degree of similarity with the tools and angiographic results of the actual procedure.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> However, these simulators lack the tactile experience that is paramount in percutaneous procedures. On the other hand, 3D simulators offer a physical experience in an accurate patient-specific anatomy. Itagaky et al. treated multiple splenic artery aneurysms in a 3D-printed model, and then used the same combination of guide catheter, base catheter and microcatheter to successfully treat the patient, with minimized radiation dose.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> In a benchmark validation study, two cases of endovascular aortic aneurysm repair were compared with patient-specific stent deployment 3D models. By comparing stent positions in simulations and post-operative scans, the authors determined the simulation-predicted stent locations and shapes with an accuracy of a few millimeters.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> In the field of complex structural heart intervention, 3D printing has been used to select device sizes, although not in a fully simulated procedure setting.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first report of simulated coronary PCI in a 3D patient-specific model. Considering patient frailty, complexity of the anatomy and previous bifurcation PCI, we decided to replicate the coronary anatomy using a 3D model to simulate the intervention procedure in the catheterization laboratory using standard materials.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Computed tomography, magnetic resonance imaging or 3D echocardiography data sets have often been used to render the 3D volumes.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> However, 3D angiography based on planar angiographic images may be useful. These methods are familiar to interventional cardiologists and they may provide a more detailed anatomy due to providing higher spatial resolution than non-invasive modalities. However, their reliability may be impaired in highly eccentric plaques (which was not our case) because they use only two projections to derive the 3D geometry of the vessel of interest.</p><p id="par0050" class="elsevierStylePara elsevierViewall">According to the European Society of Cardiology guidelines, it is advisable to treat in-stent restenosis with either DES or drug-coated balloons (class I, level of evidence A).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> In fact, drug-coated balloons were second only to everolimus-eluting stents to treat in-stent restenosis in a meta-analysis of over 5000 patients. They were superior to both balloon angioplasty and bare metal stents.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> Intracoronary imaging with OCT provides a detailed assessment of in-stent restenosis mechanisms,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11,12</span></a> and thus it should be considered to investigate the cause of restenosis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> In keeping with this, we chose to treat the patient with a DES and used intracoronary imaging to guide both procedures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this proof-of-concept procedure we have shown that patient-specific simulation is feasible to guide the treatment strategy of complex coronary artery disease. We used a realistic PCI simulator in which we included patient-specific coronary anatomy in order to plan and practice a complex procedure beforehand, predict possible complications and gain confidence. In this way, the operator was able to use standard diagnosis and PCI tools in the catheterization laboratory environment, enabling testing and training for several endovascular skills. Furthermore, the final results of PCI can be seen using angiography, intravascular imaging and by directly inspecting the 3D anatomic model. Using this approach, we treated a critical ostial Cx stent restenosis with a simulation of the procedure the day before the actual PCI, using similar tools and achieving similar results. We hypothesize that complex procedures will be guided by patient-specific training in the future, if these encouraging preliminary results are replicated and tested in clinical trials. However, we must bear in mind that some complications are difficult to predict, such as edge dissection, iatrogenic coronary thrombosis, spasm, no-reflow, perforation or retained material due to calcification. In addition, simulated vessel wall properties are critical for procedure replication. This simple model has limitations in simulating calcifications/previous stents in the vessel wall, which might lead to differing balloon behavior when comparing the real and simulated procedures.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There are still some challenges in implementing patient-specific simulation using medical 3D printing. First, 3D-model accuracy heavily depends on image quality and precise segmentation to generate final volume. Secondly, it is challenging to replicate the complexity of coronary structure, namely with uneven calcification or previous stent implantation. Finally, this technology is demanding and requires multidisciplinary expertise, including cardiovascular imaging, software processing, 3D printing and materials selection.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">This case illustrates the feasibility and accuracy of a 3D patient-specific simulation-guided treatment strategy for coronary PCI. This technology may improve operators’ experience, increase their confidence and offer a trustworthy anatomic model to test devices and complex intervention techniques.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">Manuel Oliveira Santos, Eduardo Oliveira Santos and João Silva Marques have created and developed the custom interventional cardiology simulator SimulHeart<span class="elsevierStyleSup">®</span>.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no other conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1047914" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec999304" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1047915" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec999303" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack353907" "titulo" => "Acknowledgements" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-27" "fechaAceptado" => "2018-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec999304" "palabras" => array:3 [ 0 => "3D printing" 1 => "Percutaneous coronary intervention" 2 => "Simulation training" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec999303" "palabras" => array:3 [ 0 => "Impressão 3D" 1 => "Intervenção coronária percutânea" 2 => "Treino em simulação" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The field of three-dimensional printing applied to patient-specific simulation is evolving as a tool to enhance intervention results. We report the first case of a fully simulated percutaneous coronary intervention in a three-dimensional patient-specific model to guide treatment.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An 85-year-old female presented with symptomatic in-stent restenosis in the ostial circumflex and was scheduled for percutaneous coronary intervention. Considering the complexity of the anatomy, patient setting and intervention technique, we elected to replicate the coronary anatomy using a three-dimensional model. In this way, we simulated the intervention procedure beforehand in the catheterization laboratory using standard materials. The procedure was guided by optical coherence tomography, with pre-dilatation of the lesion, implantation of a single drug-eluting stent in the ostial circumflex and kissing balloon inflation to the left anterior descending artery and circumflex. Procedural steps were replicated in the real patient's treatment, with remarkable parallelism in angiographic outcome and luminal gain at intracoronary imaging.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this proof-of-concept report, we show that patient-specific simulation is feasible to guide the treatment strategy of complex coronary artery disease. It enables the surgical team to plan and practice the procedure beforehand, and possibly predict complications and gain confidence.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O campo da impressão tridimensional aplicado à simulação específica de doente está a evoluir como uma ferramenta para aperfeiçoar os resultados das intervenções terapêuticas. Pretendemos descrever o primeiro caso de simulação completa de intervenção coronária percutânea, num modelo tridimensional específico de doente, para guiar o procedimento.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Uma doente de 85 anos com reestenose <span class="elsevierStyleItalic">intra-stent</span> sintomática no óstio da artéria circunflexa foi referenciada para intervenção coronária percutânea. Considerando a complexidade da anatomia, o contexto clínico e a técnica de intervenção, decidimos reproduzir a anatomia coronária com o uso de um modelo tridimensional. Desse modo, simulámos antecipadamente a intervenção no laboratório de hemodinâmica com material habitual. O procedimento foi guiado por tomografia de coerência óptica, com pré-dilatação da lesão, implantação de um <span class="elsevierStyleItalic">stent</span> farmacoativo na circunflexa ostial e insuflação <span class="elsevierStyleItalic">kissing balloon</span> na descendente anterior e circunflexa. As etapas do procedimento foram reproduzidas no tratamento real, com um paralelismo notável nos resultados angiográficos e ganho luminal avaliado por imagem intracoronária.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Com esta prova de conceito, demonstramos que a simulação específica de doente é exequível para guiar a estratégia de tratamento de doença coronária complexa, possibilitando o planeamento antecipado do procedimento, possivelmente prevendo complicac¿o¿es e adquirindo mais confianc¿a.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1368 "Ancho" => 2457 "Tamanyo" => 272852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The steps for creating a patient-specific 3D coronary model for simulation are depicted. They include segmentation of the coronary angiography in order to create a 3D patient-specific digital model, and post-processing to obtain a flexible and transparent patient-specific physical model that could be connected to the custom interventional cardiology simulator SimulHeart<span class="elsevierStyleSup">®</span>. The images on the bottom show the ostial circumflex stenosis model on visual inspection (left) and the post-intervention result after stent placement (right).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1698 "Ancho" => 3167 "Tamanyo" => 433902 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Side-by-side display of matched angiographic appearance (Panel A) and OCT imaging (Panel B) of patient-specific simulated procedure and actual procedure for comparative purposes. (Panel A) Angiographic images depicting the sequential procedural steps from diagnosis to final surgical result. (Panel B) OCT still frames of minimal luminal area before intervention and the final result after stent implantation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A practical guide to cardiovascular 3D printing in clinical practice: overview and examples" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Abudayyeh" 1 => "B. Gordon" 2 => "M.M. 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Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcin.2017.07.017" "Revista" => array:6 [ "tituloSerie" => "JACC Cardiovasc Interv" "fecha" => "2017" "volumen" => "10" "paginaInicial" => "2340" "paginaFinal" => "2341" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29102578" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack353907" "titulo" => "Acknowledgements" "texto" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The authors acknowledge the contribution of Paulo Carvalho for technical support with the fluoroscopy equipment for the simulated procedure.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003700000006/v2_201806270452/S0870255117309459/v2_201806270452/en/main.assets" "Apartado" => array:4 [ "identificador" => "29263" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos Clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003700000006/v2_201806270452/S0870255117309459/v2_201806270452/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117309459?idApp=UINPBA00004E" ]
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| 2023 Maio | 93 | 34 | 127 |
| 2023 Abril | 55 | 6 | 61 |
| 2023 Maro | 60 | 29 | 89 |
| 2023 Fevereiro | 61 | 22 | 83 |
| 2023 Janeiro | 45 | 26 | 71 |
| 2022 Dezembro | 79 | 20 | 99 |
| 2022 Novembro | 66 | 38 | 104 |
| 2022 Outubro | 79 | 36 | 115 |
| 2022 Setembro | 43 | 32 | 75 |
| 2022 Agosto | 48 | 36 | 84 |
| 2022 Julho | 72 | 38 | 110 |
| 2022 Junho | 59 | 18 | 77 |
| 2022 Maio | 62 | 47 | 109 |
| 2022 Abril | 56 | 48 | 104 |
| 2022 Maro | 64 | 63 | 127 |
| 2022 Fevereiro | 65 | 39 | 104 |
| 2022 Janeiro | 54 | 39 | 93 |
| 2021 Dezembro | 63 | 29 | 92 |
| 2021 Novembro | 69 | 45 | 114 |
| 2021 Outubro | 157 | 50 | 207 |
| 2021 Setembro | 48 | 23 | 71 |
| 2021 Agosto | 52 | 30 | 82 |
| 2021 Julho | 22 | 23 | 45 |
| 2021 Junho | 48 | 30 | 78 |
| 2021 Maio | 76 | 37 | 113 |
| 2021 Abril | 122 | 20 | 142 |
| 2021 Maro | 122 | 21 | 143 |
| 2021 Fevereiro | 116 | 19 | 135 |
| 2021 Janeiro | 61 | 21 | 82 |
| 2020 Dezembro | 70 | 21 | 91 |
| 2020 Novembro | 107 | 12 | 119 |
| 2020 Outubro | 43 | 20 | 63 |
| 2020 Setembro | 79 | 16 | 95 |
| 2020 Agosto | 57 | 15 | 72 |
| 2020 Julho | 89 | 24 | 113 |
| 2020 Junho | 63 | 13 | 76 |
| 2020 Maio | 59 | 8 | 67 |
| 2020 Abril | 93 | 20 | 113 |
| 2020 Maro | 90 | 17 | 107 |
| 2020 Fevereiro | 208 | 27 | 235 |
| 2020 Janeiro | 90 | 8 | 98 |
| 2019 Dezembro | 62 | 7 | 69 |
| 2019 Novembro | 64 | 13 | 77 |
| 2019 Outubro | 68 | 16 | 84 |
| 2019 Setembro | 96 | 6 | 102 |
| 2019 Agosto | 74 | 16 | 90 |
| 2019 Julho | 76 | 13 | 89 |
| 2019 Junho | 61 | 20 | 81 |
| 2019 Maio | 75 | 8 | 83 |
| 2019 Abril | 59 | 21 | 80 |
| 2019 Maro | 447 | 11 | 458 |
| 2019 Fevereiro | 162 | 7 | 169 |
| 2019 Janeiro | 69 | 11 | 80 |
| 2018 Dezembro | 27 | 14 | 41 |
| 2018 Novembro | 84 | 14 | 98 |
| 2018 Outubro | 88 | 27 | 115 |
| 2018 Setembro | 37 | 14 | 51 |
| 2018 Agosto | 32 | 18 | 50 |
| 2018 Julho | 43 | 32 | 75 |
| 2018 Junho | 35 | 26 | 61 |
| 2018 Maio | 16 | 34 | 50 |
Mostrar tudo
