Longitudinal Evaluation of Congenital Cardiovascular Surgical Performance and Skills Retention Using Silicone-Molded Heart Models.

Objective: Hands-on surgical training (HOST) for congenital heart surgery (CHS), utilizing silicone-molded models created from 3D-printing of patients' imaging data, was shown to improve surgical skills. However, the impact of repetition and frequency of repetition in retaining skills has not been previously investigated. We aimed to longitudinally evaluate the outcome for HOST on two example procedures of different technical difficulties with repeated attempts over a 15-week period. Methods: Five CHS trainees were prospectively recruited. Repair of coarctation of the aorta (CoA) and arterial switch operation (ASO) were selected as example procedures of relatively low and high technical difficulty. Procedural time and technical performance (using procedure-specific assessment tools by the participant, a peer-reviewer, and the proctor) were measured. Results: Coarctation repair performance scores improved after the first repetition but remained unchanged at the follow-up session. Likewise, CoA procedural time showed an early reduction but then remained stable (mean [standard deviation]: 29[14] vs 25[15] vs 23[9] min at 0, 1, and 4 weeks). Conversely, ASO performance scores improved during the first repetitions, but decreased after a longer time delay (>9 weeks). Arterial switch operation procedural time showed modest improvements across simulations but significantly reduced from the first to the last attempt: 119[20] versus 106[28] min at 0 and 15 weeks, P = .049. Conclusions: Complex procedures require multiple HOST repetitions, without excessive time delay to maintain long-term skills improvement. Conversely, a single session may be planned for simple procedures to achieve satisfactory medium-term results. Importantly, a consistent reduction in procedural times was recorded, supporting increased surgical efficiency.

State-of-the-art silicone molded models for simulation of arterial switch operation: Innovation with parting-and-assembly strategy.

Background: Three-dimensional (3D) printed models are widely accepted for use in training of various surgical procedures for congenital heart disease; however, their physical properties have been considered suboptimum for procedures. We created silicone molded models produced using a novel "parting and assembly" strategy and compared their suitability for hands-on training with that of conventional 3D printed models. Methods: Computed tomography imaging data from 2 patients with transposition of the great arteries were used. The heart was divided into multiple parts (atria, ventricles, great arteries, coronary arteries, and valves), and molds of each part were created. The parts reproduced by silicone molding were assembled using an adhesive agent. In an online course, 2 silicone molded models and 1 3D printed model were used for training of 34 surgeons. A questionnaire was distributed to these surgeons aimed at assessing the suitability of the models for the arterial switch operation (ASO). Results: The silicone molded models showed excellent anatomic detail, high elasticity, and high resistance to tearing. The cost per model, based on the production of 50 models, was slightly higher for the silicone molded models compared with the 3D printed models. All 26 surgeons who completed the questionnaire reported that the silicone molded models provided sufficient anatomic information, but only 19% said the same for the 3D printed models. All surgeons also considered the silicone models to be realistic when passing a needle, cutting vessels, suturing, and excision of the coronary buttons, as opposed to <46% for the 3D printed models. Conclusions: Silicone molding of models for the ASO is feasible by applying a "parting and assembly" strategy. Silicone molded models provide excellent physical properties that are far superior to those of 3D printed models for surgical simulation.

Deformity-Correcting Ankle Fusions With Patient-Specific 3D Operative Planning and 3D-Printed Cut Guides: Report of 2 Cases.

CASE: We report 2 cases of severe arthrogrypotic clubfeet presenting with multiplanar ankle deformities. Two patients (3 ankles) were treated with deformity-correcting ankle fusions using 3D preoperative planning and 3D-printed patient-specific cut guides. This technique enabled safe, accurate, and efficient surgical correction with good clinical outcomes. At 1 year, physical function and patient outcome measures improved. CONCLUSION: In the setting of complex multiplanar deformities of the foot and ankle, the use of 3D preoperative planning and 3D-printed cut guides is a safe and accurate adjunct to ankle fusion.

3D Modeling and Printing in Congenital Heart Surgery: Entering the Stage of Maturation.

3D printing allows the most realistic perception of the surgical anatomy of congenital heart diseases without the requirement of physical devices such as a computer screen or virtual headset. It is useful for surgical decision making and simulation, hands-on surgical training (HOST) and cardiovascular morphology teaching. 3D-printed models allow easy understanding of surgical morphology and preoperative surgical simulation. The most common indications for its clinical use include complex forms of double outlet right ventricle and transposition of the great arteries, anomalous systemic and pulmonary venous connections, and heterotaxy. Its utility in congenital heart surgery is indisputable, although it is hard to "scientifically" prove the impact of its use in surgery because of many confounding factors that contribute to the surgical outcome. 3D-printed models are valuable resources for morphology teaching. Educational models can be produced for almost all different variations of congenital heart diseases, and replicated in any number. HOST using 3D-printed models enables efficient education of surgeons in-training. Implementation of the HOST courses in congenital heart surgical training programs is not an option but an absolute necessity. In conclusion, 3D printing is entering the stage of maturation in its use for congenital heart surgery. It is now time for imagers and surgeons to find how to effectively utilize 3D printing and how to improve the quality of the products for improved patient outcomes and impact of education and training.

Development of a dynamic Chest Wall and operating table simulator to enhance congenital heart surgery simulation.

BACKGROUND: The Hands-On Surgical Training in Congenital Heart Surgery (HOST-CHS) program using 3D printed heart models has received positive feedback from attendees. However, improvements were necessary in the simulator set up to replicate the ergonomics experienced in the operating room. This paper illustrates the development of a dynamic chest wall and operating table simulator to enhance the simulation experience. METHODS: The simulator was designed to address the limitations with the existing set up. This included a suboptimal operating position, unrealistic surgical exposure and limitations in illuminating the operative field and recording procedures. A combination of computer-aided design and various 3D-printing techniques were used to build the components. The simulator's usefulness was evaluated by surgeons who attended the 5th annual HOST course via a questionnaire. RESULTS: The simulator consists of three components; an operating table simulator which allows height adjustment and pitch-and-roll motion; a suture retraction disc, which holds sutures under tension to improve exposure; and a pediatric chest wall cavity to replicate a surgeon's access experience during surgery. Nineteen surgeons completed the questionnaire. All surgeons agreed that the addition of the simulator was acceptable for surgical simulation and that it helped replicate the ergonomics experienced in the operating room. CONCLUSIONS: The inclusion of the HOST-CHS simulator adds value to simulation in congenital heart surgery (CHS) as it replicates the view and exposure a surgeon experiences. Improvements like these will help develop high-fidelity simulation programs in CHS, which could be utilized to train surgeons globally.

Simulation of semilunar valve function: computer-aided design, 3D printing and flow assessment with MR.

BACKGROUND: The structure of the valve leaflets and sinuses are crucial in supporting the proper function of the semilunar valve and ensuring leaflet durability. Therefore, an enhanced understanding of the structural characteristics of the semilunar valves is fundamental to the evaluation and staging of semilunar valve pathology, as well as the development of prosthetic or bioprosthetic valves. This paper illustrates the process of combining computer-aided design (CAD), 3D printing and flow assessment with 4-dimensional flow magnetic resonance imaging (MRI) to provide detailed assessment of the structural and hemodynamic characteristics of the normal semilunar valve. METHODS: Previously published geometric data on the aortic valve was used to model the 'normal' tricuspid aortic valve with a CAD software package and 3D printed. An MRI compatible flow pump with the capacity to mimic physiological flows was connected to the phantom. A peak flow rate of 100 mL/s and heart rate of 60 beats per minute were used. MRI measurements included cine imaging, 2D and 4D phase-contrast imaging to assess valve motion, flow velocity and complex flow patterns. RESULTS: Cine MRI data showed normal valve function and competency throughout the cardiac cycle in the 3D-printed phantom. Quantitative analysis of 4D Flow data showed net flow through 2D planes proximal and distal to the valve were very consistent (26.03 mL/s and 26.09 mL/s, respectively). Measurements of net flow value agreed closely with the flow waveform provided to the pump (27.74 mL/s), confirming 4D flow acquisition in relation to the pump output. Peak flow values proximal and distal to the valve were 78.4 mL/s and 63.3 mL/s, respectively. Particle traces of flow from 4D-phase contrast MRI data demonstrated flow through the valve into the ascending aorta and vortices within the aortic sinuses, which are expected during ventricular diastole. CONCLUSION: In this proof of concept study, we have demonstrated the ability to generate physiological 3D-printed aortic valve phantoms and evaluate their function with cine- and 4D Flow MRI. This technology can work synergistically with promising tissue engineering research to develop optimal aortic valve replacements, which closely reproduces the complex function of the normal aortic valve.

Conjugation and Evaluation of Small Hydrophobic Molecules to Triazole-Linked siRNAs.

Short interfering RNAs (siRNAs) have tremendous potential as a new class of next-generation therapeutics; however, their progress is lagging due to issues related to stability, biodistribution, and cell-membrane permeability. To overcome these issues, there is widespread interest in chemically modifying siRNAs. In this study, siRNAs that contain a triazole-backbone unit with pyrimidine-modified hydrophobic substituents were synthesized and examined for their gene-silencing activity. In our study, we generated a library of siRNAs that target both a plasmid reporter system and an endogenous gene target, bcl-2. Our results indicate that these unique modifications are well tolerated within the RNA interference pathway. In addition, a cholesterol-modified triazole-linked siRNA targeting the exogenous target firefly luciferase was capable of gene-silencing at levels greater than 80% in the absence of a carrier complex.

Synthesis of triazole-nucleoside phosphoramidites and their use in solid-phase oligonucleotide synthesis.

Triazole-backbone oligonucleotides are macromolecules that have one or more triazole units that are acting as a backbone mimic. Triazoles within the backbone have been used within oligonucleotides for a variety of applications. This unit describes the preparation and synthesis of two triazole-nucleoside phosphoramidites [uracil-triazole-uracil (UtU) and cytosine-triazole-uracil (CtU)] based on a PNA-like scaffold, and their incorporation within oligonucleotides.

Evaluation of siRNAs that contain internal variable-length spacer linkages.

The most widely accepted mechanism of RNAi-silencing involves the RNA-induced silencing complex (RISC) liberating the active antisense strand from the sense strand of an siRNA duplex to form an active RISC-antisense complex. This involves cleaving the sense strand between positions 9 and 10 from the 5' end of the strand prior to dissociation. Destabilizing modifications near the center of the duplex in some cases can enhance the efficacy of the resultant construct and may trigger an alternative mechanism through which the sense strand is removed. By introducing alkyl spacers of varying lengths near or within the sense strand's cleavage site, this study illustrates that siRNAs, in most cases, retained potent RNAi-silencing activity. Our results highlight that by substituting the scissile phosphodiester linkage on the sense strand with non-cleavable alkyl chains provides a novel and alternative method to destabilize the central region of siRNAs.

Efficient synthesis and cell-based silencing activity of siRNAS that contain triazole backbone linkages.

An efficient synthesis of siRNAs modified at the backbone with a triazole functionality is reported. Through the use of 4,4'-dimethoxytrityl (DMT) phosphoramidite chemistry, triazole backbone dimers were site-specifically incorporated throughout various siRNAs targeting both firefly luciferase and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene transcripts as representatives of an exogenous and endogenous gene, respectively. Following the successful silencing of the firefly luciferase reporter gene, triazole-modified siRNAs were also found to be capable of silencing GAPDH in a dose-dependent manner. Backbone modifications approaching the 3'-end on the sense strand were tolerated without compromising siRNA potency. This study highlights the compatibility of triazole-modified siRNAs within the RNAi pathway, and the modification's potential to impart favorable properties to siRNAs designed to target other endogenous genes.