New operations for truncus arteriosus repair using partial heart transplantation: Exploring the surgical design space with 3-dimensional printed heart models

Central MessageThree-dimensional printed heart models are used to contribute new operations for truncus arteriosus repair using partial heart transplantation. Three-dimensional printed heart models are used to contribute new operations for truncus arteriosus repair using partial heart transplantation. Heart valve replacement has poor outcomes in infants because state-of-the-art homografts do not grow or self-repair. For homograft replacement of semilunar valves in the systemic position, the in-hospital mortality is 40%1Woods R.K. Pasquali S.K. Jacobs M.L. Austin E.H. Jacobs J.P. Krolikowski M. et al.Aortic valve replacement in neonates and infants: an analysis of the society of thoracic surgeons congenital heart surgery database.J Thorac Cardiovasc Surg. 2012; 144: 1084-1089Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar and structural deterioration occurs within months. In the pulmonary position, structural deterioration mandates replacement after an average of 5 years.2Wells W.J. Arroyo Jr., H. Bremner R.M. Wood J. Starnes V.A. Homograft conduit failure in infants is not due to somatic outgrowth.J Thorac Cardiovasc Surg. 2002; 124: 88-96Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar For homograft replacement of truncal valves,3Sierra J. Beghetti M. Kalangos A. Truncus arteriosus repair with double aortic homograft.J Card Surg. 2004; 19: 252-253Crossref PubMed Scopus (6) Google Scholar the infant mortality is 50% to 75%.4McElhinney D.B. Reddy V.M. Rajasinghe H.A. Mora B.N. Silverman N.H. Hanley F.L. Trends in the management of truncal valve insufficiency.Ann Thorac Surg. 1998; 65: 517-524Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 5Russell H.M. Pasquali S.K. Jacobs J.P. Jacobs M.L. O’Brien S.M. Mavroudis C. et al.Outcomes of repair of common arterial trunk with truncal valve surgery: a review of the society of thoracic surgeons congenital heart surgery database.Ann Thorac Surg. 2012; 93 (discussion 169): 164-169Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 6Elkins R.C. Steinberg J.B. Razook J.D. Ward K.E. Overholt E.D. Thompson Jr., W.M. et al.Correction of truncus arteriosus with truncal valvar stenosis or insufficiency using two homografts.Ann Thorac Surg. 1990; 50: 728-733Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 7Henaine R. Azarnoush K. Belli E. Capderou A. Roussin R. Planché C. et al.Fate of the truncal valve in truncus arteriosus.Ann Thorac Surg. 2008; 85: 172-178Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar Therefore, there is an urgent clinical need for growing and self-repairing heart valve implants. We developed a new approach for delivering growing and self-repairing heart valve implants that is based on transplantation. This approach is called “partial heart transplantation” because only the part of the heart containing the heart valve is transplanted. The rationale for partial heart transplantation is that neonates with orthotopic heart transplants reach adult size without the need for reintervention8Lin Y. Davis T.J. Zorrilla-Vaca A. Wojcik B.M. Miyamoto S.D. Everitt M.D. et al.Neonatal heart transplant outcomes: a single institutional experience.J Thorac Cardiovasc Surg. 2021; 162: 1361-1368Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar because transplanted hearts grow9Bernstein D. Kolla S. Miner M. Pitlick P. Griffin M. Starnes V. et al.Cardiac growth after pediatric heart transplantation.Circulation. 1992; 85: 1433-1439Crossref PubMed Scopus (32) Google Scholar and failure of the transplanted semilunar valves is exceedingly rare.10Valente M. Faggian G. Billingham M.E. Talenti E. Calabrese F. Casula R. et al.The aortic valve after heart transplantation.Ann Thorac Surg. 1995; 60: S135-S140Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 11Goekler J. Zuckermann A. Osorio E. Brkic F.F. Uyanik-Uenal K. Laufer G. et al.Cardiac surgery after heart transplantation: elective operation or last exit strategy?.Transplant Direct. 2017; 3: e209Crossref PubMed Scopus (13) Google Scholar, 12Goerler H. Simon A. Warnecke G. Meyer A.L. Kuehn C. Haverich A. et al.Cardiac surgery late after heart transplantation: a safe and effective treatment option.J Thorac Cardiovasc Surg. 2010; 140: 433-439Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 13Mitchell R.N. Jonas R.A. Schoen F.J. Pathology of explanted cryopreserved allograft heart valves: comparison with aortic valves from orthotopic heart transplants.J Thorac Cardiovasc Surg. 1998; 115: 118-127Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar Partial heart transplantation uses living homografts. Living homografts differ from conventional homografts in 3 important aspects (Table E1). First, living homografts are tissue typed. Second, living homograft ischemia times are minimized. Third, partial heart transplant recipients receive immunosuppression. These differences keep the living homografts viable, allowing them to grow and self-repair. Therefore, immunologically quiescent partial heart transplants might last a lifetime. Partial heart transplantation is particularly suitable for neonatal truncal valve replacement because Ross pulmonary auto-transplantation is not possible. However, the surgical design space for partial heart transplantation in truncus arteriosus remains unexplored. We hypothesized that 3-dimensional (3D) printed heart models can be used to design new operations for truncus arteriosus repair using partial heart transplantation. The 3D printed models (Figure E1) of structurally normal hearts and hearts with truncus arteriosus were purchased from the Hospital for Sick Children in Toronto. Briefly, electrocardiographically gated computed tomography scans were used to acquire imaging data that were postprocessed for 3D modeling using threshold-based segmentation and computer-aided design processes.14Yoo S.J. Hussein N. Peel B. Coles J. van Arsdell G.S. Honjo O. et al.3D modeling and printing in congenital heart surgery: entering the stage of maturation.Front Pediatr. 2021; 9: 621672Crossref PubMed Scopus (29) Google Scholar, 15Yoo S.J. Thabit O. Kim E.K. Ide H. Yim D. Dragulescu A. et al.3D printing in medicine of congenital heart diseases.3D Print Med. 2015; 2: 3Crossref PubMed Google Scholar, 16Peel B. Lee W. Hussein N. Yoo S.J. State-of-the-art silicone molded models for simulation of arterial switch operation: innovation with parting-and-assembly strategy.JTCVS Tech. 2022; 12: 132-142Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The models were then printed using a PolyJet Photopolymer (TangoPlus, Stratasys Ltd) that emulates cardiac tissue and is validated for use in surgical simulation.14Yoo S.J. Hussein N. Peel B. Coles J. van Arsdell G.S. Honjo O. et al.3D modeling and printing in congenital heart surgery: entering the stage of maturation.Front Pediatr. 2021; 9: 621672Crossref PubMed Scopus (29) Google Scholar Operations for partial heart transplantation were developed in multiple iterations to identify and refine critical surgical steps (Figure 1). Operation 1 involves transplantation of the cardiac outflow tract en bloc. The donor heart is procured in the usual fashion. On the back table, the living homograft containing both the aortic and pulmonary roots is dissected (Figure 2). The recipient ascending aorta is divided, and the truncal valve is interrogated to confirm that it is not repairable. The donor living homograft (Figure E2) is then used to replace the truncal valve. Operation 2 involves separate transplantation of the aortic and pulmonary roots. The donor living homografts are separately dissected like conventional homografts.17Barratt-Boyes B.G. A method for preparing and inserting a homograft aortic valve.Br J Surg. 1965; 52: 847-856Crossref PubMed Scopus (70) Google Scholar,18Longmore D.B. Lockey E. Ross D.N. Pickering B.N. The preparation of aortic-valve homografts.Lancet. 1966; 2: 463-464Abstract PubMed Google Scholar The implant operation resembles a double root replacement with conventional homografts.3Sierra J. Beghetti M. Kalangos A. Truncus arteriosus repair with double aortic homograft.J Card Surg. 2004; 19: 252-253Crossref PubMed Scopus (6) Google Scholar,19Bobylev D. Sarikouch S. Tudorache I. Cvitkovic T. Söylen B. Boethig D. et al.Double semilunar valve replacement in complex congenital heart disease using decellularized homografts.Interact Cardiovasc Thorac Surg. 2019; 28: 151-157Crossref PubMed Scopus (9) Google Scholar Operation 3 involves subcoronary implantation of the aortic valve. The donor living homografts are dissected as for operation 2. The donor aortic valve sinuses of Valsalva are resected, leaving just the heart valve. The recipient operation involves excision of the dysfunctional truncus valve and implantation of the living homograft in a subcoronary position (Figure 2). Continuity of the right ventricle and pulmonary arteries is then established using the pulmonary living homograft. Operation 4 involves preservation of the native truncal valve and use of a living homograft as a growing right ventricle to pulmonary artery conduit using standard surgical techniques. Three-dimensional printed models have been used for surgical planning,20Yoo S.J. van Arsdell G.S. 3D printing in surgical management of double outlet right ventricle.Front Pediatr. 2017; 5: 289Crossref PubMed Scopus (34) Google Scholar, 21Hussein N. Kasdi R. Coles J.G. Yoo S.J. Use of 3-dimensionally printed heart models in the planning and simulation of surgery in patients with Raghib syndrome (coronary sinus defect with left superior vena cava).JTCVS Tech. 2020; 2: 135-138Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 22Contreras J.R. Villemain O. Marini D. Dragulescu A. Yoo S.J. Barron D.J. Utility of a bespoke 3-dimensional printed model in complex transposition.JTCVS Tech. 2021; 7: 199-202Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar surgical training,16Peel B. Lee W. Hussein N. Yoo S.J. State-of-the-art silicone molded models for simulation of arterial switch operation: innovation with parting-and-assembly strategy.JTCVS Tech. 2022; 12: 132-142Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar morphology teaching, and patient education.14Yoo S.J. Hussein N. Peel B. Coles J. van Arsdell G.S. Honjo O. et al.3D modeling and printing in congenital heart surgery: entering the stage of maturation.Front Pediatr. 2021; 9: 621672Crossref PubMed Scopus (29) Google Scholar We use 3D printed models to develop new operations for truncus arteriosus repair using partial heart transplantation. The key advantage of this approach is that high-fidelity 3D printed models of hearts with truncus arteriosus are readily available. In contrast, access to human specimens with truncus arteriosus for surgical research is limited and there are no large animal models for truncus arteriosus. Therefore, only donor operations can be evaluated using natural tissue (Figure E2). The major challenge in using 3D printed models is that commercially available materials suboptimally simulate natural tissue elastic properties and strength.16Peel B. Lee W. Hussein N. Yoo S.J. State-of-the-art silicone molded models for simulation of arterial switch operation: innovation with parting-and-assembly strategy.JTCVS Tech. 2022; 12: 132-142Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar As a result, the 3D printed tissues do not stretch well and poorly hold fine Prolene sutures. The proposed operations have distinct indications. Operations 1 and 2 are new treatment options for neonates with unrepairable truncal valve dysfunction. Operation 3 avoids coronary reimplantation but is only suitable for children with a sufficiently large native truncal root that accommodates subcoronary implantation of the living homograft valve. Operation 4 offers a growing right ventricle to pulmonary artery conduit for neonates who do not require truncal valve replacement. Additionally it is possible to repair the truncal valve using living homograft valve cusp tissue (Operation 5), but the available 3D models are not suitable for simulating surgery of the truncal valve itself. These operations have important advantages over orthotopic heart transplants. First, orthotopic heart transplants invariably fail from ventricular dysfunction over time,8Lin Y. Davis T.J. Zorrilla-Vaca A. Wojcik B.M. Miyamoto S.D. Everitt M.D. et al.Neonatal heart transplant outcomes: a single institutional experience.J Thorac Cardiovasc Surg. 2021; 162: 1361-1368Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar whereas partial heart transplants do not include the ventricle. Of note, semilunar valve dysfunction of orthotopic heart transplants is exceedingly rare,11Goekler J. Zuckermann A. Osorio E. Brkic F.F. Uyanik-Uenal K. Laufer G. et al.Cardiac surgery after heart transplantation: elective operation or last exit strategy?.Transplant Direct. 2017; 3: e209Crossref PubMed Scopus (13) Google Scholar,12Goerler H. Simon A. Warnecke G. Meyer A.L. Kuehn C. Haverich A. et al.Cardiac surgery late after heart transplantation: a safe and effective treatment option.J Thorac Cardiovasc Surg. 2010; 140: 433-439Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar and the semilunar valves are spared in fulminant rejection of orthotopic heart transplants.13Mitchell R.N. Jonas R.A. Schoen F.J. Pathology of explanted cryopreserved allograft heart valves: comparison with aortic valves from orthotopic heart transplants.J Thorac Cardiovasc Surg. 1998; 115: 118-127Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar Second, the donor pool for living homografts is larger than for orthotopic heart transplants because hearts with low ventricular function and slow progression to donation after cardiac death are viable sources.23Sherard C. Atteya M. Vogel A.D. Bisbee C. Kang L. Turek J.W. et al.Partial heart transplantation can ameliorate donor organ utilization.J Card Surg. 2022; 37: 5307-5312Crossref PubMed Scopus (9) Google Scholar Third, stopping immunosuppression would simply turn the living homograft into a conventional homograft.24Mehrotra R. Srivastava S. Airan B. Koicha M.A. Mehra N.K. Venugopal P. et al.Aortic valve replacement with a homovital valve.Tex Heart Inst J. 1997; 24: 221-222PubMed Google Scholar We used 3D printing to design new operations for truncus arteriosus repair using partial heart transplantation. To our knowledge, this is the first application of 3D printing to design new operations.

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