Cardiac imaging specialist Dr. Shafkat Anwar explains how MRI facilitates better management of patients born with heart defects, while technologies such as 3D printing can improve surgical planning, efficiency, outcomes and training.
Mhm. Yeah. Hello. My name is Shafqat Anwar and I'm a pediatric cardiologist here at UCSF and I am the cardiology director of cardiac MRI and the co director for the Center for Advanced Three Plus Technologies. And today I'd like to talk with you about the use of cardiac MRI and three T plus technologies in congestive heart disease. So the talk will be in two parts. We'll start with discussing the role of cardiac MRI in pediatric and congenital heart disease. And after that, I'm going to pivot and talk with you about the use of what we're calling three D plus technologies in congenial heart disease for pre procedural planning, procedural simulation, training, education and patient and family counseling. I do have a couple of disclosures. First I will be discussing the use of gadolinium contrast which is an off label use in Pete's cardiac MRI. And I'm also a consultant and shareholder for printer press which is a medical device startup company here in the bay Area. So to start off with, I'd like to say that overall survival has improved dramatically in congenital heart disease from the time the first pediatric congenital cardiovascular procedure was performed. This is dr gross closing a patent doctor arterial sis about 80 years ago. There has been dramatic improvements all across the board in Qianjiang heart disease. Several studies have now shown longitudinal e that there have been improvements in mortality and survival uh in whatever form of congenital heart disease we want to talk about from the simple to the complex. However, our metrics of what we're calling. Doing well increases and goes way beyond survival and the metrics that we're interested in most In 2019. Our issues such as long term morbidity coming out of the operating room with the fewest amount of residual legions, reducing the number of re interventions on our patients, improving neurodevelopmental outcomes and improving the length of hospitalization and inpatient complications. And finally, we always have an eye towards the cost of health care and overall improvements in outcomes should go in tandem with decreasing health care costs. At the same time, we face considerable challenges in the management of our patients with congenital heart disease. At a referral center like UCSF, we get patients who have extremely high complexity and undergo high risk surgery in the first few days of life sometimes or they have multiple surgeries each with compounding risk. We also have multiple care teams which is a strength and these teams have diverse experiences and perspectives. However, communication and coordination between these teams can be challenging. And finally, in pediatrics, we have our families who are the primary decision makers for our patients and that does involved another layer of complexity and turn to this technology such as cardiac MRI, which I believe and I hope to share with you in this talk is going to help us improve the management of our patients and hopefully improve our outcomes in Xinjiang heart disease cardiac MRI is particularly helpful as a diagnostic modality because it offers us unlimited imaging planes. It is the imaging gold standard for cardiac function and flow. Cardiac MRI allows us to assess extra cardiac structures and provides excellent tissue characterization and by that I mean, cardiac MRI allows us to figure out what is the composition of structures such as my cardi, um blood flow etcetera. It lets us assess not only the anatomy but also the physiology of complex heart defects and cardiac MRI involves no ionizing radiation, which is a significant benefit. And finally, Cardiac MRI allows us to perform some advanced applications such as three D. Printing 40 flow and get a very sensitive assessment of my cardio mechanics. In summary cardiac MRI allows us to take a heart that is extremely complex and in the schematic, I'm basically showing you a single ventricle heart where essentially we have a large hole in the heart, a single outflow instead of two outflows and in this particular patient, another large hole in the heart between the two collecting chambers. And this patient has been paleo hated with a particular type of surgery called a Fontane procedure and has bilateral bidirectional connections between the systemic veins and the pulmonary artery. Thus we're diverting all systemic venus or the oxygenated blood out to the lungs, completely bypassing the heart and then returning oxygenated blood through the pulmonary veins to the heart. And this allows a patient with extremely complex physiology and anatomy to survive. However, very difficult to image and appreciate with traditional imaging cardiac MRI allows us to take a very complex appearing heart and reconstructed so we can visualize all the pertinent structures such as the ventricles the outflows and not only assess the anatomy but also the physiology in a referral centers such as UCSF. We like to use cardiac M. R. I. To its fullest potential. Thus I'm going to show some of our most common use cases and its impact on not just a cardiology but the entire medical enterprise. So what I'm showing here in the four blue figures are are most common uses of cardiac MRI. Assessment of congenital heart disease planning for surgeries, interventional cardiac procedures and assessment of valve disease and vascular apathy. In addition, cardiac MRI supports our um more sub specialized services within cardiology such as our electrophysiology team. When they assess complex arrhythmias are cardiomyopathy and heart failure team and also our pulmonary hypertension service. Furthermore, our cardiac MRI expertise can be extended to referral facilities. Um and we are happy to assess patients from multiple sites um to assess their heart disease and plan for surgeries and beyond pediatrics. These technologies are very helpful in the adult congenital population. Finally, the additional bubbles that I'm showing in the dark red shows the extension of cardiac M. R. I. Beyond the heart center such as to services such as oncology in the assessment of genetic syndromes, suggest Turner's and working with other surgical subspecialties such as general surgery and assessment of practice disorders or scoliosis. Working with our neuromuscular team and patients with muscular dystrophy and working with our hematology specialists for patients with him a global open these and those with iron deposition. So now I'm going to pivot a bit from cardiac MRI to the use of advanced applications And these applications of cardiac MRI include three D printing. Advanced visualization techniques such as extended reality. And these include technologies like augmented virtual or mixed reality. Furthermore, Cardiac MRI can be applied to assess flow in four dimensions and also my cardio mechanics for today's talk. I'm mainly going to focus on three D. Printing and extended reality technologies such as a R. V. R. Or M. R. And for these, I'd like to say that we use not just MRI, but also cardiac ct and three D echo at the heart center. We really focus on using multi modality imaging individualized to the patient. So I'm going to start off with three D printing. And the first question before anything else I think is why three D printing? Because overall, as I started by saying, we're doing pretty well in terms of outcomes in Kandahar disease. However, I think three D printing allows us to do better. So this is a particular example of a patient with complex congenital heart disease. And I'd like to talk about this phenomenon along the lines of flashlight spotlight and daylight. Now this is an echocardiogram of a patient and it's going to sweep through the anatomy and as we play the video, this one sweep using ultrasound is actually showing us most of the complex disorders that this patient has within the heart. Now that is very difficult to tell just off one sweep. However, an experienced echocardiography for can make this diagnosis from the sweep. However, that level of experience takes decades to accumulate and there can be errors, interpretation and not only that even two very experienced echocardiography can have different perspectives on the anatomy, leading to errors. We can get a more detailed look at the anatomy using three D technologies such as CT or MRI. And this is a contrast enhanced MRI. Going through the same dataset, scroll through it again. And what I'm going to start the show is what was seen by echo in this particular patient there is a large atrial septal defect or a hole in the collecting chambers between the right and the left atrium and there are probably abnormal connections. Also we thought between the atria and the ventricles. So this is the patient's mitral valve going to the left ventricle and it is a bit difficult to tell which atrium leads to this ventricle. As the video progresses this the patients try to spit valve going to the right ventricle and again, a bit difficult to tell which of these collecting chambers goes into this ventricle. So we wondered about this patient having what's called a crisscross heart or discordant atria ventricular connections. And as I scroll further, it appears that these patients great arteries, the pulmonary artery and the aorta. Both seemed to come off this ventricle here, which is the right ventricle. So we thought this patient had something called double outlet right ventricle and having the MRI added a lot of diagnostic accuracy to this. Now, this diagnosis so far had already been made by the echo sweep again, recording quite a bit of experience to try to make the diagnosis. What was not diagnosed well by echo, because echo is limited when it comes to the assessment of extra cardiac structures are the fact that the patients lungs were completely collapsed on the left side. What I'm showing here is complete left lung collapse and King king of the patient's left pulmonary artery here, whereas the right lung looks pretty normal. And as the video progresses, we also noticed that the patient's aorta is quite narrow right there. So cardiac MRI allows us to get an excellent evaluation of the inter cardiac and also the extra cardiac structures and what we can do after that is do a volume rendering such as this, which shows the vascular structure as well. In this case, I was able to tell the surgeon that we need to do an arch repair right there and here is the left pulmonary artery narrowing. That would also need to be taken care of. However, all this so far still does not show the inter cardiac anatomy with a lot of three dimensional detail. And what the surgeons really need to see is how do we fix this heart? And what I've shown you so far is the use of conventional imaging and standard of care. Well I'll show you. Next is the value add of cardiac three D. Printing. This is the patient's same heart made from the same MRI dataset that I showed you. And what we're seeing very simply from this three D. Printed model is that there's a large hole in the heart through which this catheter is passing and these are the relationships between the systemic veins that come into the patient's atrial. And there are normal relationships between the patients left atrium and left ventricle and also the right atrium and right ventricle. And all I'm saying to the surgeon here is that we just need to close this ventricular septal defect and divert blood from this left ventricle to the aorta. So in essence the three D. Printed model lets you hold the heart and practice the surgery. When we make these three D. Printed models out of flexible and comfortable materials, you're actually able to do a whole simulated surgery before even stepping foot into the operating room. Thus we think three D. Printed models will be able to allow our surgeons two operate more efficiently and come out of the operating room with fewer residual lesions. So now that we've talked a little bit about why three D. Printing. I'll show you about how we do three D. Printing and we'll do this through this video. So this is a contrast enhanced data set basically showing the entire slab of the cardiac anatomy going from the diaphragm up to the neck. This can also be done from contrast enhanced CT. After we have the data set. What I'm showing here is a multiplayer reconstruction and I have the good fortune of working with extremely talented engineers who take the three D. Contrast enhanced data set and do a process that's called segmentation here. What we're basically doing is separating out the important anatomy and I'm supervising this process that the engineer is going through and the engineer is basically marking off different parts of the anatomy for us to be able to make a surgical plan. This process is time and labor intensive. However we feel that it is worth it in order to produce a highly accurate model. And here the engineer has made an electronic three model and the engineer has sent it back to me this is me looking at the model inspecting all the areas for accuracy and comparing it to the source images that I had gotten. And this is me giving feedback back to the engineer that I'd like to see more of the structure of interest and after that we sent our model off to the printer and it literally prints out lair by lair with very high accuracy. We can pick up the models from the printer. It goes through a process of cleaning out support structures from within the model. And here I'm showing two different types of models. One is a cardiac and one is a skull model. Now that was how we do three D printing. And this flow sheet here basically shows what the use cases are of three D. Printing in medicine. This is beyond just cardiac. I'm talking about a global look at medical three D printing. Most of what I've talked about so far are surgical models such as models that we use for preoperative planning or models that we use to print out for intra operative guides. Now this would be for usually boning procedures such as orthopedics or craniofacial of course at an institution such as UCSF. We serve many different functions where teaching institution and models for education are extremely valuable because these help bring down the level of complexity and hopefully overall increase the pace at which our learners are picking up very complex defects and their understanding of anatomy. So we use models quite often for patient education, learner education and also for surgical stimulation which I'll talk about later today. Um finally uh up and coming application of 3D printing is the use of medical devices, especially in pediatrics, innovation for pediatric specific medical devices has always lagged behind adult applications. However additive manufacturing using 3D printing is allowing us to start leveling that playing field and we're looking towards making pediatric specific implantable medical devices using this kind of advanced manufacturing technology. Finally, bioprinting using tissue engineering Is a very, very exciting up and coming field mostly in the research environment at this time, but has tremendous potential for tissue regeneration using 3D printing. Mhm. So we recently collected up the available literature on three D. Printing in congenital heart disease and the state of the review and our summary from a review of the literature was that cardiac three D printing is accurate, provides precise pre surgical planning, results in improvements in training, education and technical skills and increases patient and caregiver understanding of the disease process. And finally there is early data from the E. N. T. And orthopedic fields showing there are starting to be reductions in operating room time using three D. Printed models. So we feel that we're at a point now where three D. Printing is allowing us a bit of a paradigm shift where for our trainees prior to having three D. Printed models, the training paradigm had been see one do one teach one. However, with models, we're now moving towards better simulator based learning for our experts before the models, there was significant time, effort and complications spent figuring out things in the operating room and the cath lab and hopefully we're starting to move the needle on some of these with detailed pre surgical planning. With the models. Hopefully avoiding pitfalls that we can anticipate by doing a detailed pre surgical session. Using the models in the O. R. Hopefully we're being able to see around corners and seeing through blood. And overall we are seeing that the three D. Models are allowing us to do better contingency planning. As in when we go in for a very complex case, we can have plan A. But because we've done a pre procedural simulation, we can think through what would be plan B, plan C or bailout strategies to optimize the patient's outcome. And finally, for our patients and caregivers prior to the models, there had been significant complexity and ambiguity trying to understand highly complex anatomies and also complex decision making regarding surgeries leading to possibly a suboptimal informed consent. And we are starting to see that using the models, there is now increased understanding and involvement on the part of our caregivers in the patient's disease process and decision making. So now I'm just going to go through a few cases to show some of the uses of three D. Printing in complex Qianjiang heart disease. The first case is a patient who is eight months of age with citizen versus double outlet, right ventricle and mile post great arteries. I've printed this model with the patient's liver to show the cardiac anatomy and here is the patient's apex, pointing to the right abnormally. Using the liver allows us a great stand to see how everything is oriented. So abdomen is down here. Here are the patient's systemic veins going into the heart. As we can see it's on the wrong side, the patient's left side. And the intra cardiac anatomy essentially is double outlet, right ventricle. With this right ventricle giving off the patients the aorta and the pulmonary artery. And what I'm showing in this preoperative plan here is the patients ventricular septal defect can be closed this way to allow emptying of blood from the left ventricle out to the aorta and the passage of blood under the VSD baffle to effectively create a two ventricle circulation. This patient had this particular surgery and this is the patient's intra operative trans esophageal echo. And what we're showing here is the patient's left ventricle going out the aorta. There is no obstruction of blood flow by color. This patient did well. The next patient is a four year old with hetero tracks E. S. Plenty to an unbalanced atrial ventricular canal and a double outlet right ventricle. And this patient had already gone through a bilateral bidirectional glenn procedure and we were planning for this patient's total cable pulmonary connection or a Fontane. However, with this particular patient, as you can see here, the patient's pulmonary veins are coming back quite absent lateral. The right side of veins. Over here and the left side of veins far apart over here. So the concern for this patient for doing a Fontane procedure is if we do the traditional Fontane, it would compress quite a bit on this left side of pulmonary veins right there for this particular patient. We made use of both the multicolor rigid models and the three D. Printed model with flexible material. And this is a recorded video of the patient's surgical planning session. The page the surgeon here is looking down the flexible model that he's cut into and planning out the pathway of the Fontane. In the end, we did a modified extra cardiac Fontane that did not compress the pulmonary veins and the patient did well. This is the patient's anatomy as shown by the three D. Printed model. And this is the same anatomy seen in the operating room. And here is the extra cardiac Fontane. The next case I wanted to show is the use of three printing for extra cardiac and vascular surgery in this patient with charlie follow pulmonary atresia macros, there's a particular patient who was quite sick beforehand and had had several um cardiopulmonary arrests and we decided to fix these patients um ted map because anatomy in stages. So this is what the original anatomy looks like. And we are viewing the patient from the posterior aspect here is the patient's aorta and the patient did not have any true native pulmonary arteries and the blood supply to the lungs were provided by these network of collateral vessels shown here in red. Yeah. Using the three printed model we planned out the surgery and here, I'm showing the intra thoracic anatomy with the heart removed. Just to show the minefield that our surgeons are operating in. Basically we're working through networks of nerves, arteries, veins, lymphatic, each of which, if damaged during the surgery would lead to complications, increased hospitalization, increased morbidity, etcetera. Using the three d. Printed model, the surgeon was able to operate and put in a Bt shunt. This is the images from the O. R. Showing the surgeon looking at the model and looking at the inter cardiac anatomy at the same time and planning his dissection and be Tyshawn placement. And so the first procedure involved a Bt shunt to the right. We brought the patient back a couple of months later, put in a bt shunt to the left and finally, after a short recovery we unify localize the all the collaterals to this conduit and for the moment had left the VSD open to optimize the cardiac physiology, three d. Printing so far I've shown for uses in cardiac surgery. However, the technology has also been used for per Catania's interventions. This is a patient who had to travel to follow that had been repaired and I'm showing the dilated our bot and main pulmonary artery here and it was felt that this patient's um main pulmonary artery and our bot was probably a little bit too large to undergo a traditional per cutaneous valve placement with either a melody or an Edwards valve. Whoever the approach we took to this particular patient was printing out a three D. Printed model and implanting a stent for sizing purposes to establish a landing zone and after that was felt to be successful, we tried the procedure in the patient and here is the actual case we had put in a stent. We allowed that stent to industrialize and brought the patient back a couple of months later and put in an Edwards valve and this is the and graham out of the main pulmonary artery, showing no significant pulmonary regurgitation. And for this particular patient, we were able to successfully implant the pulmonary valve without doing surgery. Moving on for part titanius, I'd like to talk a little bit about the use of three D. Printing for our patients with adult congenital heart disease. As we know, patients in this population as they get older tend to have pretty bad echocardiogram thick windows. So we can use this technology to clean up the windows and get a much better, more precise look at the patients into cardiac anatomy. This particular patient is a 29 year old male with double outlet right ventricle who had undergone a Rastelli procedure with the right ventricle to pulmonary conduit and was a high risk patient because he already had three star anatomies and he had now developed progressive exercise intolerance. We made a three D. Model of this patient to try to understand some pretty complex outflow tract obstruction. And what this treaty model is showing essentially is that this is the patients BSD patch and this patch had buckled in and now there was a residual VSD. You're able to see this patient catheter that I've put from the right ventricle, crossing the VSD into the left ventricle there. And as this patch, it buckled in a complex obstruction had formed right under the left ventricle. When we model this patient, we wanted to give a surgeon's view and here is the surgeon's view, looking down the aorta and what you can see in green right there is that BSD patch that had buckled in and this is the same exact anatomy from the surgeon's perspective in the operating room. As you can see, looking down the aorta. Again we're seeing where the VSD. Patches and the bundle of LV muscle that the surgeon was able to respect very precisely using the three D. Model as a guide and that patient also did well. The next case I'd like to show is one of a ventricular assist device planning. This is also an adult congenital patient who had the transposition of the great arteries. So this is the patient's systemic right ventricle as you can see heavily Trebek related. However, the patient had started having heart failure symptoms and progressive dysfunction of the systemic right ventricle. At this point, the decision tree was whether the patient gets a transplant ventricular assist device and medical management was not an option as he was already maximized on medical therapy and we decided to proceed with the ventricular assist device for this particular patient. We printed the entire chest out from stem to stern. So this is diaphragm and this is the thoracic inlet and everything in between. We printed in a multi material model. So these ribs have the density and texture of ribs and the shafts, soft tissue inside feels like my cardi um et cetera for this particular patient. What we're showing is the placement and the different steps of the ventricular assist device. And here we are putting in the sewing ring, putting in the vat itself and then closing up the chest. So conceptually with the simulation, we are able to see that the ventricular assist device sits well and after the chest is closed, everything fits well. We're also able to respect quite a lot of tribulations from the systemic right ventricle in order to fit this vat in well. And during our entry into the heart. This the aorta was densely adherent to the sternum and basically fell apart, which would be a catastrophic complication. During the surgery itself. However, we did have the heads up from the model to put this patient on bypass before the surgery to avoid major complication. So far, we've looked at the use cases for three D. Printing mainly in the operating room. However, we find that this technology affects the entire heart center. Uh We're using these for discussions with our our team which includes surgeons but also includes anesthesiologists, cardiologists, profusion ists and nursing. We're using this to overall enrich the imaging team that includes radiology and cardiology and post operatively. The medical team learns more about the cardiac anatomy and specifically about the surgeries that were done to anticipate any postoperative complications that arise next. We're gonna turn a little bit towards the use of three D. Printing for education and surgical simulation. This is the echo clip that had shown earlier which shows the anatomy of interest. However, this type of echocardiogram thick interpretation takes decades to master. However, we can print out entire libraries of three D. Printed models and use them to teach our next generation as we are doing now at UCSF. Finally, the benefits of surgical simulation go beyond the novice to the experience. This is dr Mahan Ready who's our senior cardiothoracic surgeon at UCSF. And he is using one of our models to plan out a complex inter cardiac procedure. And this is just one of our recent examples. The use of three D. Printing has benefits as I had reference for our patients and caregivers as well. The use of three D. Printed models are very important in my opinion as we give the parents the exact anatomy of the heart defects of their child and talk through the procedures that they can anticipate and hopefully come to a better informed consent process. This is just some of the feedback that we received back from our families. We do tend to ask them about their experiences afterwards and overall the report that their understanding of the child's anatomy and anticipated procedures is enhanced through the use of three D. Printed models. And this is just some data from my prior institution where we looked at the use of three D. Printed models over time period and overall the accuracy scores comparing the models to what was found in the O. R. Was quite high. This was from a period of three years showing a mean accuracy score of 4.5 out of five and from the caregivers point of view, all patients and caregivers who completed a questionnaire, reported the models for very helpful in helping them understand the anatomy. This has also been shown in multi institutional studies from this paper from 2017, for example, looking at 10 centers and 40 patients with complex heart disease, they found that three D. Models accurately replicated anatomy And 96% of surgeons agreed or strongly agreed that three d. Printed models provided better understanding of the morphology and improve surgical planning. Furthermore, they found that three d. models changed surgical decision making in 19 of the 40 cases And consideration of a three d. model refined the planned by ventricular repair, achieving an improved surgical correction in eight cases and in four of the cases that were initially considered for a conservative or single ventricle affiliation inspection of the three D. Model enabled successful by ventricular repair. I'm going to transition now to the use of electronic modeling. Um Not all our patients require physical three D. Printed models. And here at UCSF we can use um extended reality technologies such as VR. A. Are etcetera and this is a particular patient in whom we used mixed reality for surgical planning. It's a single ventricle patient with the Fontane who had developed a large pseudo aneurysm and also clots within the Fontane circuit as shown in the dark material there as the video plays. I'm basically doing a surgical plan where I'm showing the surgeons that areas of pseudo aneurysm and also showing the surge in the areas of clot here from the ct images. This is a cot clot right by the patient's coronary artery and the native aorta which would need to be removed. And as this video plays, I'm going to show a mixed reality system that we use called echo pixel that allows a surgeon to take a virtual scalpel and cut in and out of the anatomy. Basically we're using a stylist which is our electronic scalpel and we're being able to rapidly render to show the different areas of interests here, the lungs and the airways And in full 363 d planes. The surgeon is able to cut through the anatomy and compared to the source CT images to very precisely plan out the approaches through the rapid rendering technology we're able to show the pseudo aneurysm, there's the clot in the L. P. A graft and as the video proceeds, just showing the different planes that the surgeon would go through in order to perform this high risk surgery for this particular patient, things went according to plan and here we're showing areas where the thrombosis was respected out of the pseudo aneurysm, the LP A graph with the clot in it that was taken out and this was the clot inside the coronary artery that was all successfully resected and the patient recovered well and was discharged. We're using this XR technology is also in medical education. This is one example at our Anatomy learning center where our medical students are applying these technologies to learn anatomy and along with my collaborator in anesthesiology we're applying these technologies to teach our anesthesiology residents the basics of congenital heart disease here you see sf with structured three D. Technologies across the entire enterprise across UCSF and UCSF health. Um starting with these five Hubs of three D Technologies. We are located at the Parnassus campus at Mission Bay at san Francisco General at the villa and at Mount Zion and we are progressing with our partnership with Oakland Children's and also our strength is in our synergistic partnerships throughout the specialists and experts at UCSF such as our partnerships with the bio fabrication and design center, the quantitative image processing center and our affiliations with the department of anatomy and the Makers lab here at UCSF. The Center for Advanced Three Technologies is led by physician leaders by the three founding departments at the pediatric Heart Center, Orthopedics and radiology And these are our capabilities. The 3D printing is performed on multiple printers that enable models for different subspecialties. We have software for virtual surgical planning of the type that had shown and beyond advanced visualization systems that take advantage of technologies such as augmented virtual or mixed reality platforms for visualizing complex anatomy. We are able to run pretty complex by mechanical analysis and simulations to understand complex physiology in addition to anatomy And finally the use of three D scanning technologies today we discussed the use of cardiac MRI in the management of patients with pediatric and ken jeong heart disease and also the use of cardiac three D. Printing and three D. Plus technologies. Hopefully to improve outcomes in this patient population. To refer patient to cardiology here at UCSF, Please contact us at the pediatric heart center at 415353 2008. And to learn more about our cardiac three D. Plus program. Please visit us at our website and I thank you for your attention. Mm. Yeah
