A role for ultra-high resolution three-dimensional printed human heart models.

INTRODUCTION: Echocardiography is essential for diagnosing and assessing the severity of perioperative structural and functional heart disease. Yet, educational opportunities to better understand echocardiography-based cardiac anatomy remain limited by the two-dimensional display, lack of anatomic details, variability of heart models, and costs and global access of training. METHODS: We performed micro computed tomography of human heart specimens not suitable for orthotopic transplantation. We created high-resolution computational 3D models of different human hearts, sliced them in the different recommended American Society of Echocardiography views, and 3D printed them using different materials. RESULTS: We scanned, 3D modeled, and 3D printed a variety of human hearts both healthy and diseased. We have made the models available in the cardiac operating rooms and routinely use them for teaching anesthesia residents and cardiothoracic anesthesia fellows about basic and advanced echocardiographic views, cardiopulmonary bypass cannulation strategies, and valvular pathology and planned interventions. CONCLUSION: We have generated a library of 3D printed hearts to display the recommended echocardiographic views as a unique educational tool designed to safely accelerate the understanding of absolute and relative human cardiac anatomy and pathology, especially related to gaining advanced appreciation of clinically employed perioperative echocardiography.

Right Ventricular Shape Feature Quantification for Evaluation of Pulmonary Hypertension: Feasibility and Preliminary Associations With Clinical Outcome Submitted for Publication.

This study aimed to demonstrate feasibility of statistical shape analysis techniques to identify distinguishing features of right ventricle (RV) shape as related to hemodynamic variables and outcome data in pulmonary hypertension (PH). Cardiovascular magnetic resonance images were acquired from 50 patients (33 PH, 17 non-PH). Contemporaneous right heart catheterization data were collected for all individuals. Outcome was defined by all-cause mortality and hospitalization for heart failure. RV endocardial borders were manually segmented, and three-dimensional surfaces reconstructed at end diastole and end systole. Registration and harmonic mapping were then used to create a quantitative correspondence between all RV surfaces. Proper orthogonal decomposition was performed to generate modes describing RV shape features. The first 15 modes captured over 98% of the total modal energy. Two shape modes, 8 (free wall expansion) and 13 (septal flattening), stood out as relating to PH state (mode 13: r = 0.424, p = 0.002; mode 8: r = 0.429, p = 0.002). Mode 13 was significantly correlated with outcome (r = 0.438, p = 0.001), more so than any hemodynamic variable. Shape analysis techniques can derive unique RV shape descriptors corresponding to specific, anatomically meaningful features. The modes quantify shape features that had been previously only qualitatively related to PH progression. Modes describing relevant RV features are shown to correlate with clinical measures of RV status, as well as outcomes. These new shape descriptors lay the groundwork for a noninvasive strategy for identification of failing RVs, beyond what is currently available to clinicians.

A clinically applicable strategy to estimate the in vivo distribution of mechanical material properties of the right ventricular wall.

A clinically applicable approach to estimate the in vivo mechanical material properties of the heart wall is presented. This optimization-based inverse estimation approach applies a shape-based objective functional combined with rigid body registration and incremental parameterization of heterogeneity to use standard clinical imaging data along with simplified representations of cardiac function to provide consistent and physically meaningful solution estimates. The capability of the inverse estimation algorithm is evaluated through application to two clinically obtained human datasets to estimate the passive elastic mechanical properties of the heart wall, with an emphasis on the right ventricle. One dataset corresponded to a subject with normal heart function, while the other corresponded to a subject with severe pulmonary hypertension, and therefore expected to have a substantially stiffer right ventricle. Patient-specific pressure-driven bi-ventricle finite element analysis was used as the forward model and the endocardial surface of the right ventricle was used as the target data for the inverse problem. By using the right ventricle alone as the target of the inverse problem the relative sensitivity of the objective function to the right ventricle properties is increased. The method was able to identify material properties to accurately match the corresponding shape of the simplified forward model to the clinically obtained target data, and the properties obtained for the example cases are consistent with the clinical expectation for the right ventricle. Additionally, the material property estimates indicate significant heterogeneity in the heart wall for both subjects, and more so for the subject with pulmonary hypertension.

A Spectral Finite Element Approach to Modeling Soft Solids Excited with High-Frequency Harmonic Loads.

An approach for efficient and accurate finite element analysis of harmonically excited soft solids using high-order spectral finite elements is presented and evaluated. The Helmholtz-type equations used to model such systems suffer from additional numerical error known as pollution when excitation frequency becomes high relative to stiffness (i.e. high wave number), which is the case, for example, for soft tissues subject to ultrasound excitations. The use of high-order polynomial elements allows for a reduction in this pollution error, but requires additional consideration to counteract Runge's phenomenon and/or poor linear system conditioning, which has led to the use of spectral element approaches. This work examines in detail the computational benefits and practical applicability of high-order spectral elements for such problems. The spectral elements examined are tensor product elements (i.e. quad or brick elements) of high-order Lagrangian polynomials with non-uniformly distributed Gauss-Lobatto-Legendre nodal points. A shear plane wave example is presented to show the dependence of the accuracy and computational expense of high-order elements on wave number. Then, a convergence study for a viscoelastic acoustic-structure interaction finite element model of an actual ultrasound driven vibroacoustic experiment is shown. The number of degrees of freedom required for a given accuracy level was found to consistently decrease with increasing element order. However, the computationally optimal element order was found to strongly depend on the wave number.

Effect of opaque wraps for pulse oximeter sensors: randomised cross-over trial.

BACKGROUND: Evidence is lacking as to whether ambient light or phototherapy light could interfere with pulse oximeter performance. METHODS: In this randomised cross-over trial, we recruited neonates of gestation >24 weeks. Consented infants were randomly assigned to either pulse oximeter sensor with opaque wrap or without opaque wrap. Nellcor and Masimo sensors were applied simultaneously to different feet for 10 min of recording. Infants were crossed over to the other intervention for a further 10 min, totalling 20 min recording per infant. Primary outcome was faster acquisition of data with shielding of pulse oximeter sensor as compared with not shielding. RESULTS: A total of 96 babies were recruited. There was no difference in primary outcome of time taken to display valid data between the two groups (opaque wrap: 12.73±3.1 s vs no opaque wrap: 13.16±3.3 s, p=0.27). There was no difference in any of the secondary outcomes (percentage of valid data points, percentage of time saturation below target, and so on) between the two groups in both pulse oximeters. Masimo sensor readings displayed a higher mean oxygen saturation (mean difference of 2.85, p=0.001) and lower percentage of time saturation below 94% (mean difference of -27.8, p=0.001) than Nellcor in both groups. There was no difference in any of the outcomes in babies receiving phototherapy (n=21). CONCLUSION: In this study, shielding the pulse oximeter sensor from ambient light or phototherapy light did not yield faster data acquisition or better data quality. TRIAL REGISTRATION NUMBER: ISRCTN10302534.

Predicting responses to mechanical ventilation for preterm infants with acute respiratory illness using artificial neural networks.

Infants born prematurely are particularly susceptible to respiratory illness due to underdeveloped lungs, which can often result in fatality. Preterm infants in acute stages of respiratory illness typically require mechanical ventilation assistance, and the efficacy of the type of mechanical ventilation and its delivery has been the subject of a number clinical studies. With recent advances in machine learning approaches, particularly deep learning, it may be possible to estimate future responses to mechanical ventilation in real time, based on ventilation monitoring up to the point of analysis. In this work, recurrent neural networks are proposed for predicting future ventilation parameters due to the highly nonlinear behavior of the ventilation measures of interest and the ability of recurrent neural networks to model complex nonlinear functions. The resulting application of this particular class of neural networks shows promise in its ability to predict future responses for different ventilation modes. Towards improving care and treatment of preterm newborns, further development of this prediction process for ventilation could potentially aid in important clinical decisions or studies to improve preterm infant health.

Mapped Chebyshev pseudo-spectral method for simulating the shear wave propagation in the plane of symmetry of a transversely isotropic viscoelastic medium.

Shear wave elastography is a versatile technique that is being applied to many organs. However, in tissues that exhibit anisotropic material properties, special care must be taken to estimate shear wave propagation accurately and efficiently. A two-dimensional simulation method is implemented to simulate the shear wave propagation in the plane of symmetry in transversely isotropic viscoelastic media. The method uses a mapped Chebyshev pseudo-spectral method to calculate the spatial derivatives and an Adams-Bashforth-Moulton integrator with variable step sizes for time marching. The boundaries of the two-dimensional domain are surrounded by perfectly matched layers to approximate an infinite domain and minimize reflection errors. In an earlier work, we proposed a solution for estimating the apparent shear wave elasticity and viscosity of the spatial group velocity as a function of rotation angle through a low-frequency approximation by a Taylor expansion. With the solver implemented in MATLAB, the simulated results in this paper match well with the theory. Compared to the finite element method simulations we used before, the pseudo-spectral solver consumes less memory and is faster and achieves better accuracy.

Modeling transversely isotropic, viscoelastic, incompressible tissue-like materials with application in ultrasound shear wave elastography.

In this paper, we propose a method to model the shear wave propagation in transversely isotropic, viscoelastic and incompressible media. The targeted application is ultrasound-based shear wave elastography for viscoelasticity measurements in anisotropic tissues such as the kidney and skeletal muscles. The proposed model predicts that if the viscoelastic parameters both across and along fiber directions can be characterized as a Voigt material, then the spatial phase velocity at any angle is also governed by a Voigt material model. Further, with the aid of Taylor expansions, it is shown that the spatial group velocity at any angle is close to a Voigt type for weakly attenuative materials within a certain bandwidth. The model is implemented in a finite element code by a time domain explicit integration scheme and shear wave simulations are conducted. The results of the simulations are analyzed to extract the shear wave elasticity and viscosity for both the spatial phase and group velocities. The estimated values match well with theoretical predictions. The proposed theory is further verified by an ex vivo tissue experiment measured in a porcine skeletal muscle by an ultrasound shear wave elastography method. The applicability of the Taylor expansion to analyze the spatial velocities is also discussed. We demonstrate that the approximations from the Taylor expansions are subject to errors when the viscosities across or along the fiber directions are large or the maximum frequency considered is beyond the bandwidth defined by radii of convergence of the Taylor expansions.

Non-invasive assessment of elastic modulus of arterial constructs during cell culture using ultrasound elasticity imaging.

Mechanical strength is a key design factor in tissue engineering of arteries. Most existing techniques assess the mechanical property of arterial constructs destructively, leading to sacrifice of a large number of animals. We propose an ultrasound-based non-invasive technique for the assessment of the mechanical strength of engineered arterial constructs. Tubular scaffolds made from a biodegradable elastomer and seeded with vascular fibroblasts and smooth muscle cells were cultured in a pulsatile-flow bioreactor. Scaffold distension was computed from ultrasound radiofrequency signals of the pulsating scaffold via 2-D phase-sensitive speckle tracking. Young's modulus was then calculated by solving the inverse problem from the distension and the recorded pulse pressure. The stiffness thus computed from ultrasound correlated well with direct mechanical testing results. As the scaffolds matured in culture, ultrasound measurements indicated an increase in Young's modulus, and histology confirmed the growth of cells and collagen fibrils in the constructs. The results indicate that ultrasound elastography can be used to assess and monitor non-invasively the mechanical properties of arterial constructs.

A new approach to kinematic feature extraction from the human right ventricle for classification of hypertension: a feasibility study.

This work presents a novel approach to analyze the function of the human right ventricle (RV) by deriving kinematic features of the relative change in shape throughout the cardiac cycle. The approach is anatomically consistent, allows direct comparison across populations of individuals, and potentially provides new metrics to improve the diagnosis and understanding of cardiovascular diseases such as pulmonary hypertension (PH). The details of the approach are presented, which includes a variation of harmonic topological mapping and proper orthogonal decomposition techniques, with particular focus on their applicability with respect to untagged cardiac imaging data. Results are shown for the decomposition of a collection of clinically obtained human RV endocardial surfaces segmented from cardiac computed tomography imaging into the fundamental shape change features for individuals both with and without PH. The features are shown to be consistent and converging towards intrinsically physiological components for the heart, and may potentially represent a new set of features for classifying the progressive change in RV function caused by PH, particularly in comparison to traditional clinical metrics.

An inverse problem approach for elasticity imaging through vibroacoustics.

A methodology for estimating the spatial distribution of elastic moduli using the steady-state dynamic response of solids immersed in fluids is presented. The technique relies on the ensuing acoustic field from a remotely excited solid to inversely estimate the spatial distribution of Young's modulus of biological structures (e.g., breast tissue). This work proposes the use of Gaussian radial basis functions (GRBF) to represent the spatial variation of elastic moduli. GRBF are shown to possess the advantage of representing smooth functions with quasi-compact support and can efficiently represent elastic moduli distributions such as those that occur in soft biological tissue in the presence of unhealthy tissue (e.g., tumors and calcifications). The direct problem consists of a coupled acoustic-structure interaction boundary-value problem solved in the frequency domain using the finite element method. The inverse problem is cast as an optimization problem in which the error functional is defined as a measure of discrepancy between an experimentally measured response and a finite element representation of the system. Nongradient based optimization algorithms are used to solve the resulting optimization problem. The feasibility of the proposed approach is demonstrated through a series of simulations and an experiment. For comparison purposes, the surface velocity response was also used for the inverse characterization as the measured response in place of the acoustic pressure.

Identification of material properties of orthotropic elastic cylinders immersed in fluid using vibroacoustic techniques.

A numerical study is presented to show the potential for using vibroacoustic-based experiments to identify elastic material properties of orthotropic cylindrical vessels immersed in fluids. Sensitivity analyses and a simulated inverse problem are shown to quantify the potential for material characterization through the use of acoustic emissions. For comparison purposes, the analyses are also shown with the normal component of the velocity at the surface of the cylinder as the measured response in place of the acoustic pressure. The simulated experiment consisted of an orthotropic cylinder immersed in water with an impact force applied to the surface of the cylinder. The material parameters of the cylinder considered in the analyses were the circumferential and longitudinal elastic moduli, and the in-plane shear modulus. The velocity response is shown to provide sufficient information for characterizing all three moduli from a single experiment. Alternatively, the acoustic pressure response is shown to provide sufficient information for characterizing only the two elastic moduli from a single experiment. The analyses show that the acoustic pressure response does not have sufficient sensitivity to the in-plane shear modulus for characterization purposes.

When does quality count?: Perceptions of hearsay testimony about child sexual abuse interviews.

This study assessed how the quality of a sexual abuse investigative interview with a child and the age of the child influence jurors' reactions to either the original interview with the child or to testimony by an adult hearsay witness (the interviewer). Participants (N = 360) were randomly assigned to 1 of 12 conditions in a 2 (type of testimony: hearsay testimony vs. child interview) x 3 (interview quality: poor, typical, or good) x 2 (age of the child: 4 years old vs. 10 years old) factorial design. Participants reached individual verdicts, answered a series of questions, and then deliberated in a group with five other participants. As predicted, jurors in the child interview conditions were more likely to find the defendant guilty if they read the good interview than if they read either the poor or the typical interview, but in the hearsay conditions verdicts did not significantly differ by interview quality. These findings suggest that there is a significant loss of information when the testimony of a hearsay witness is used in place of the actual interview with the child, and call into question the appropriateness of admitting hearsay testimony by interviewers.