If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address for reprints: Ryo Inuzuka, MD, PhD, Department of Pediatrics, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan, 113-8655.
Three-dimensional computer graphics allow quick and accurate morphological analysis of the complex double-outlet right ventricle, particularly when combined with eye-sensing stereoscopic display.
We report the case of a boy with double-outlet right ventricle, noncommitted ventricular septal defect, and subaortic stenosis who underwent pulmonary artery banding at 2 months of age. The patient was considered for biventricular repair at age 1 year. Echocardiography demonstrated intracardiac structures consistent with the diagnosis as well as sufficient volume and function of each ventricle (Figure E1). Overall, biventricular repair was deemed feasible with sufficient left ventricular outflow tract (LVOT) after the resection of the subaortic shelf. To confirm this, a high-quality rendered 3-dimensional computer graphic (3DCG) model was synthesized based on computed tomography images using real-time 3DCG software (Viewtify, SCIEMENT) (Figure 1 and Video 1). The 3DCG model was visualized using a naked-eye, eye-sensing stereoscopic display (ELF-SR1, Sony, Tokyo, Japan) (Figure E2). These virtual-reality visualization techniques allowed the surgeon to preoperatively identify the 3-dimensional (3D) positioning of the ventricular septal defect, each valve, and its supporting structures; envision the suture line for the baffle patch; and identify potential LVOT obstruction by the subaortic shelf after baffle creation.
Figure 13DCG model synthesized from computed tomography images. A, The locations of the aortic valve and pulmonary valve are indicated on the image. The ventricular septal defect is distant from the aortic valve and pulmonary valve. A discrete subaortic shelf (arrow) is protruding into the subaortic outflow tract. B, The dotted line indicates the assumed cross-section of the intracardiac baffle patch. The subaortic shelf (arrows) significantly obstructs the baffle. AV, Aortic valve; PV, pulmonary valve; VSD, ventricular septal defect.
During surgery, the subaortic muscular shelf was resected, and an intracardiac baffle was created using an oval polytetrafluoroethylene patch, forming an LVOT (Figure 2). The postoperative course was uneventful, and the patient remained stable without major problems for 1 year after the repair (Figure E1).
Figure 2Surgical procedure. Once cardiopulmonary bypass was established with ascending aortic perfusion and bicaval drainage, the right atrium was incised for inspection. Although the ventricular septal defect and subaortic shelf were seen, the aortic valve was not visualized. Top: To obtain sufficient operative space, an incision was made from the subpulmonary right ventricular free wall to the main pulmonary artery across the pulmonary annulus with the valvular leaflets preserved, and the subaortic muscular shelf was resected. Bottom: A 3 × 4.5-cm oval polytetrafluoroethylene patch was sutured from immediately below the aortic valve to the apical edge of the ventricular septal defect. After the resection of the pulmonary banding site, the main pulmonary artery and pulmonary annulus were sutured. To avoid right ventricular outflow tract stenosis, the right ventricular incision was augmented with a polytetrafluoroethylene patch. Cardiopulmonary bypass and aortic crossclamp times were 211 and 118 minutes, respectively. The minimum systemic temperature was 34.0 °C. VSD, Ventricular septal defect; PTFE, polytetrafluoroethylene.
The use of 3D modeling technology for complex congenital heart diseases, including double-outlet right ventricle, has been widely reported, most of which are related to 3D printing.
Advanced medical use of three-dimensional imaging in congenital heart disease: augmented reality. mixed reality, virtual reality, and three-dimensional printing.
3D printing facilitates the recognition of complex 3D structures; however, its creation takes hours or even days. In contrast, the recent 3DCG with high-quality, realistic, and prompt rendering accompanied by real-time changes in viewpoints, cross-sections, and rendering threshold can provide important 3D data in minutes with greater visibility than during surgery, as shown in the Video 1. Moreover, its clinical utility can be enhanced further using the emerging eye-sensing stereoscopic technology. The patient's parents provided informed written consent for the publication of this report's data. This study was approved by the University of Tokyo Hospital Ethics Committee on July 22, 2020 (No. 2701).
Screen record of the real-time 3DCG software. Once the DICOM data of original computed tomography are imported in seconds, a virtual model is instantly synthesized without any need for pre- or post-processing of the original DICOM data. Therefore, the time taken to obtain each 3DCG image from the DICOM data is virtually the same as the elapsed time of the video. With real-time changes in viewpoints, cross-sections, and rendering threshold, the high-quality 3DCG can provide clinically useful data about the 3D positioning of the ventricular septal defect, each valve, and its surrounding structures in less than 1 minute with greater visibility than during surgery, even without stereoscopic display. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00050-0/fulltext.
Screen record of the real-time 3DCG software. Once the DICOM data of original computed tomography are imported in seconds, a virtual model is instantly synthesized without any need for pre- or post-processing of the original DICOM data. Therefore, the time taken to obtain each 3DCG image from the DICOM data is virtually the same as the elapsed time of the video. With real-time changes in viewpoints, cross-sections, and rendering threshold, the high-quality 3DCG can provide clinically useful data about the 3D positioning of the ventricular septal defect, each valve, and its surrounding structures in less than 1 minute with greater visibility than during surgery, even without stereoscopic display. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00050-0/fulltext.
Appendix 1
Figure E1Preoperative and postoperative echocardiographic images. Preoperative echocardiographic images in subcostal coronal view (A) and apical long-axis view (B) demonstrate the subaortic shelf (arrow) protruding between the ventricular septum defect and aortic valve. C, Postoperative echocardiogram in parasternal long-axis view, in which the resected subaortic shelf is seen (arrowhead). AV, Aortic valve; RV, right ventricle; VSD, ventricular septal defect; LV, left ventricle.
Figure E2Overview of the 3DCG system. The 3DCG image can be stereoscopically observed on a naked-eye, eye-sensing stereoscopic display. Nonstereoscopic images are simultaneously shown on a flat monitor.
Advanced medical use of three-dimensional imaging in congenital heart disease: augmented reality. mixed reality, virtual reality, and three-dimensional printing.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
This study was approved by the University of Tokyo Hospital Ethics Committee on July 22, 2020 (No. 2701).
The patient's parents provided informed written consent for the publication of the study data.
00050-0&id=fx1.jpg){kind=link}
00050-0&id=gr1.jpg){kind=link}
00050-0&id=gr2.jpg){kind=link}
00050-0&id=fx3.jpg){kind=link}
00050-0&id=fx4.jpg){kind=link}