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3D打印用于復雜心血管手術術前模擬的 3D 打印

2020-07-08  1911

上個月,華東地區南昌市的醫生首次使用3D打印技術來協助復雜的心血管手術。在概述最終計劃之前,位于中國江西省南昌大學第二附屬醫院的術前評估團隊依靠3D打印來模擬高危重癥高危老年患者的經導管主動脈瓣置換術(TAVR)主動脈瓣狹窄。使用3D打印進行體外實驗模擬,他們能夠評估與手術相關的風險。成功的手術使他們意識到3D打印技術可以幫助其他醫師為其患者設計更多個性化的治療方案。

Last month, doctors in east China’s Nanchang city used 3D printing technology for the first time to assist a complex cardiovascular surgery. Before outlining their final plan, a pre-operative evaluation team at the Second Affiliated Hospital of Nanchang University, in China’s Jiangxi Province, relied on 3D printing to simulate a transcatheter aortic valve replacement (TAVR) surgery on a high-risk elderly patient with severe aortic valve stenosis. Using 3D printing to conduct in vitro experimental simulations they were able to assess the risks related to the surgery. The successful operation led them to acknowledge that 3D printing technology could help other physicians design more personalized treatment solutions for their patients.

主動脈瓣狹窄是一種常見的臨床心臟病,當心臟的主動脈瓣無法完全打開而阻止血液的正常流動時,會發生高發病率和高死亡率。一旦出現癥狀,如果不進行手術治療,死亡率將很高,一年和五年生存率分別為52%和22%。它是老年人最常見的瓣膜性心臟病,并隨著年齡的增長而增加。在中國,超過75歲的患者中度或重度主動脈瓣狹窄的患病率超過2%。

Aortic valve stenosis is a common clinical heart disease with high morbidity and mortality occurring when the aortic valve of the heart fails to open completely, preventing the normal flow of blood. Once symptoms appear, if surgical treatment is not performed, the mortality rate is very high, with one-year and five-year survival rates at 52% and 22%, respectively. It is the most common valvular heart disease of the elderly and increases with age. In China, the prevalence of moderate or severe aortic stenosis in patients more than 75 years old is over two percent.

根據第二附屬醫院的報道,為治療該疾病,外科醫生通常進行開胸主動脈瓣置換術,但是對于老年人和患有其他嚴重基礎疾病的人,手術風險遠大于疾病本身的風險。相反,外科醫生傾向于選擇TAVR瓣膜置換手術,因為它具有微創性,不需要體外循環并且術后恢復率很高。然而,許多并發癥仍然困擾著該手術,例如瓣環破裂,急性冠狀動脈開放性阻塞和瓣周漏。

As reported by the Second Affiliated Hospital, to treat the condition, surgeons usually perform a thoracotomy aortic valve replacement, but for the elderly and people with other serious underlying diseases, the surgical risk is much greater than the risk of the disease itself. Instead, surgeons tend to choose TAVR valve replacement surgery because it is minimally invasive, does not require extracorporeal circulation, and has a high rate of post-surgery recovery. Nevertheless, many complications still plague this procedure, such as annulus rupture, acute coronary opening obstruction, and paravalvular leakage.

中國外科醫生斷言,在TAVR手術中,他們不能直接看整個主動脈根,也不能切開心臟來觀察內部解剖結構。因此,為準備手術,他們通常僅依靠計算機斷層掃描(CT)掃描,磁共振成像(MRI)和心臟超聲檢查,這些檢查只能為他們提供患者的二維圖像和非常有限的視野。

The Chinese surgeons asserted that during the TAVR operation, they cannot directly look at the entire aortic root, nor can they cut the heart to observe the internal anatomical structure. So, to prepare for the surgery, they usually solely rely on computerized tomography (CT) scans, magnetic resonance imaging (MRI), and cardiac ultrasounds that only provide them with a two-dimensional image of the patient and a very limited field of vision.

金星A瓣膜用于術前TAVR手術的3D模型重建(來源:南昌大學第二附屬醫院)

3D model reconstruction for preoperative TAVR surgery using a Venus A valve (Credit: Second Affiliated Hospital at Nanchang University)

與傳統的計劃相比,通過將患者的二維圖像平面數據轉換為1:1全尺寸模型,外科醫生可以用來可視化和標準化非常復雜的程序,事實證明3D打印技術在術前準備中非常有用。越來越多的證據表明,這些3D打印的模型通過減少手術時間來提高患者的安全性和準確性。

Compared to traditional planning, 3D printing technology has proven extremely useful in presurgical preparations, by converting the patient’s two-dimensional image plane data into a 1:1 full- size model that surgeons can use to visualize and standardize a very complex procedure. There is growing evidence that these 3D-printed models improve patient safety and accuracy by decreasing operative times.

在第二附屬醫院心血管內科主任吳彥清的領導下,術前評估小組決定在確定手術策略之前首先進行體外實驗模擬以評估患者在手術過程中的風險。

Under the leadership of Yanqing Wu, director of the Department of Cardiovascular Medicine at the Second Affiliated Hospital, a pre-operative evaluation team decided to first conduct in vitro experimental simulations to assess the patient’s risks during surgery before determining the operation strategy.

體外TAVR手術模擬實驗(來源:南昌大學第二附屬醫院)

In vitro TAVR surgery simulation experiment (Credit: Second Affiliated Hospital at Nanchang University)

這位73歲的男性患者給外科醫生帶來了真正的挑戰。他的醫生發現了STS分數為中高風險,這是胸外科協會分數的縮寫,這是一種基于STS全國成人心臟外科手術數據庫中數據的經驗證的開放手術風險預測模型。此外,患者的術前CT掃描提示雙葉主動脈瓣,嚴重鈣化和冠狀動脈閉塞的高風險?;谒羞@些考慮,理想的是3D打印的術前方法。

The 73-year-old male patient presented a real challenge for surgeons. His physicians had detected a mid- to high-risk STS score, short for Society of Thoracic Surgery score, a validated risk-prediction model for open surgery based on data from the STS National Adult Cardiac Surgery Database. Additionally, preoperative CT scans from the patient suggested a bilobal aortic valve, severe calcification, and a high risk of coronary occlusion. Based on all these considerations, a 3D-printed presurgical approach was ideal.

有效地,3D重建和打印的真實圖像都證實了鈣化病變正在加重對左心室流出道的阻塞。然后,研究小組使用來自中國醫療設備領導者Venus Medtech的23毫米氣球進行預擴張和26毫米TAVR Venus-A瓣膜植入物進行了體外模擬實驗。

Effectively, both the 3D reconstruction and the printed real images confirmed that the calcified lesions were worsening obstruction to the left ventricular outflow. The team then conducted an in vitro simulation experiment, using a 23-millimeter balloon for predilatation and a 26-millimeter TAVR Venus-A valve implant, from Venus Medtech (a China-based leader in medical devices).

實驗結果證實,在植入瓣膜后,冠狀動脈的左開口未受到任何影響。此外,體外TAVR手術模擬實驗的結果證明可預測,足以繼續進行患者手術。最后,在各個專業團隊的合作下,患者的TAVR操作成功完成。

The experimental results confirmed that after the valve was implanted, the left coronary artery opening was not affected in any way.  Moreover, the results of the in vitro TAVR surgery simulation experiments proved predictable enough to move on to the patient surgery. Finally, with the cooperation of various professional teams, the patient’s TAVR operation was successfully completed.

外科醫生使用3D打印模型模擬TAVR手術(來源:南昌大學第二附屬醫院)

Surgeons simulate the TAVR surgery using a 3D printed model (Credit: Second Affiliated Hospital at Nanchang University)

最新的PARTNER 3系列隨機對照試驗顯示,在低?;颊咧?,TAVR可以在一年內減少死亡,中風或再次住院,優于主動脈瓣狹窄的另一種常規外科治療方法,即外科主動脈瓣置換術(SAVR)。盡管如此,并非所有的主動脈瓣狹窄患者都是低?;颊?,實際上,在南昌大學醫院接受治療的患者被認為是高?;颊?。此外,醫院專家認為,一般而言,患者應在手術前進行更徹底的評估,以真正獲得精確和個性化的藥物。

The latest PARTNER 3 series of randomized controlled trials showed that in low-risk patients, TAVR was superior to another conventional surgical treatment of aortic valve stenosis known as surgical aortic valve replacement (SAVR) at reducing death, stroke, or rehospitalization at one year. Nonetheless, not all aortic stenosis patients are low-risk, in fact, the patient treated in Nanchang University’s hospital was deemed high-risk. Moreover, the experts at the hospital considered that patients, in general, should undergo a more thorough evaluation before surgery to truly achieve precision and individualized medicine.

這與基于單方面知識的傳統治療模型截然不同。實際上,這個基于術前3D打印技術的TAVR手術示例需要心血管醫學,影像專家和心臟外科醫生進行有效的協作才能取得成功的結果。

This is a very different approach from the traditional treatment models based on unilateral know-how. In fact, this example of TAVR surgery based on presurgical 3D printing technology required effective teamwork in cardiovascular medicine, imaging experts, and cardiac surgeons to achieve successful results.

醫院聲稱,各個專業領域和技術的共同努力可以幫助設計針對不同患者的高度個性化的治療計劃,從而最大程度地提高他們的安全性。這就是為什么第二附屬醫院的TAVR團隊期望在江西省領導未來使用3D打印技術的TAVR手術,以實現更全面,更高質量的進步。

The hospital claims that the joint efforts of various professional disciplines and technology can help design highly personalized treatment plans for different patients, maximizing their safety. This is why the TAVR team of the Second Affiliated Hospital expects to lead future TAVR surgeries using 3D printing technology in the Jiangxi province to achieve more comprehensive and higher-quality progress.

文章來源:3dprint



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