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Three-Dimensional Printing Of Custom Semiflexible Aortic Root Models For Operative Planning And Surgical Proctoring Of Perceval Valve Implantation
Vishnu Vasanthan, Giovanny Casadiego, Sun Kim, Eric Herget, Naeem Merchant, Daniel Holloway, William Kent, Corey Adams.
University of Calgary, Calgary, AB, Canada.

OBJECTIVE: Clinical uptake of the Perceval rapid-deployment aortic bioprosthesis (Corcym, Saluggia, Italy) may be limited by sizing and implantation-related nuances. We use three-dimensional modeling and printing to fabricate patient-specific semiflexible aortic roots and validate their use in surgical planning and education for Perceval Valve implantation.
METHODS: Semiflexible aortic root models were 3D-designed and printed from DICOM files containing contrast-enhanced ECG-gated CTA images of the thoracic aorta of patients awaiting surgical aortic valve replacement via right anterior minithoracotomy. Aortic root segmentation was performed using open-source software (http://slicer.org). A 3D shell was generated around the lumenogram and hollowed, replicating the aortic root's interior. After converting the aortic surfaces to standard tessellation language (STL), the models were printed (Printrbot Simple Metal, Printrbot, USA) using Thermoplastic Polyurethane (NinjaFlex, NinjaTek, USA).
Model validation was performed. Prospectively, surgeons sized three de-identified models and a different operator performed the surgery without knowledge of the model's size. Retrospectively, aortic roots were printed from three patients who received Perceval Valves and sized by blinded surgeons.
RESULTS: In all cases, the models correctly predicted the intraoperative size. They also demonstrated the consequences of incorrect sizing (Figure). Undersizing resulted in poor leaflet coaptation. Oversizing resulted in pinwheeling or buckling. A prototype holder was developed for simulation of implantation, including guiding suture placement, traction-countertraction of sutures and balloon expansion.
CONCLUSIONS: Custom 3D-printed semiflexible aortic roots allowed for simulation of intraoperative sizing and can reproduce surgically relevant signs of inappropriate sizing, including oversizing (pinwheeling and buckling) and undersizing (suboptimal coaptation). This model will be useful for preoperative planning and surgical proctoring for the Perceval valve. Custom modeling may accelerate the learning curve associated with this valve and improve uptake for use in minimally invasive aortic valve surgery, combined cases, and patients with small roots.


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