Episode Transcript
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Music
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Host: Hello and welcome to this edition of Cook Children's Doc Talk. It's a very busy day here in the Child Life zone at Cook Children's so you may hear a little background noise.
Today. we're talking with Cook Children's cardiologist Steve Muyskens and plastic surgeon Han Zhuang Bae, or Z as he's known to his colleagues, about the use of 3D models and why they are especially helpful for surgeries that are more complicated and traditionally less predictable. Our 3D Lab is just one example of how medicine and imagination connect kids to life changing and lifesaving care. First, a little about our guests.
Dr. Muyskens is the Medical Director of Cardiac MRI and the 3D Lab. He earned his medical degree from University of Iowa, Carver College of Medicine, where he found his passion in pediatric cardiology. This experience helped to shape his practice and passion for cardiology. He completed his residency in pediatrics and pediatric cardiology at Washington University School of Medicine in St Louis, focusing on noninvasive imaging. He also pursued additional training in cardiovascular magnetic resonance imaging and computed tomography, and participated in a physician fellowship at Boston Children's Hospital, Harvard School of Medicine.
Since being at Cook Children's, Dr. Muyskens has developed the CMR program, and in 2015, Cook Children's Health Foundation awarded Dr. Muyskens an endowed chair to establish the 3D Lab. Currently, Dr. Muyskens directs the 3D Lab at Cook Children's in the effort to improve the wellbeing of every child in our care and our communities. By creating personalized patient specific models and tools, the lab supports enhanced surgical precision, improved patient and family education while decreasing complications.
Dr. Beh is a pediatric plastic surgeon with expertise in the treatment of craniofacial and cleft disorders. This encompasses bony and soft tissue conditions of the head and face, such as craniosynostosis treatment, including minimally invasive and open surgery, comprehensive cleft lip and palate care, as well as facial reconstruction in a wide range of congenital, acquired and traumatic disorders. As the director of The Cook Children's cleft team, Dr. Beh was instrumental in Cook Children's recognition by the American Cleft Palate and Craniofacial Association as a site that provides high quality multidisciplinary care. Dr. Beh earned his medical degree from the University of Texas Medical Branch, Galveston, and completed his residency at St Louis University School of Medicine, and completed his craniofacial surgery fellowship at Texas Children's Hospital. He is affiliated with the American Cleft Palate and Craniofacial Association, American Society of Maxillofacial Surgeons, American Society of Craniofacial Surgeons, International Society of Craniofacial Surgeons, and the American Society of Plastic Surgery.
Dr. Beh's passion for plastic surgery stems from the specialty's history of surgical innovation and problem solving. He chose to focus on craniofacial and pediatric plastic surgery as it provides the opportunity for a surgeon to develop long-term relationships with his patients as they grow into adulthood. Dr. Beh also enjoys integrating new technologies into his practice, which includes virtual surgical planning for complex procedures, utilizing custom 3D models, guides and implants during surgery, reducing the time under anesthesia while improving outcomes. Welcome and thank you both for being here.
00:03:46
Dr. Muyskens and Dr. Beh: Happy to be here. Thanks for inviting me.
00:03:48
Host: The 3D Lab began with a vision to advance cardiac outcomes, then moved into a range of specialties. Now, in addition to highly detailed heart models, the 3D Lab team works with surgeons in multiple specialties to create precise, unique copies of spines, facial features and more. So let's go back a little bit, Dr. Muyskens. I remember when you were just putting 3D printing into use for cardiology, and joined us for our 12th Doc Talk podcast. A lot has changed since then, can you talk a bit about how this started and where your program is today?
00:04:26
Dr. Muyskens: Yeah, it's been a long journey, that's for sure. I can't believe it's been almost 10 years since we started the 3D Lab. When we started it, I came from a background of cardiac MRI right to develop the cardiac MRI program. And I really love cardiac MRI because it provides a lot of really cool information and three dimensional reconstructions and data that you don't get from our other 2D modalities, like Echo and cardiac catheterization, which is really how we diagnose what's going on with kid’s hearts. Right?
Dr. Tam especially has an interest and a skill set and really complex anatomy. And so, as I developed this program, and we started providing all this additional information to him. He essentially has to … kind of create a plan preoperatively, like all surgeons do, but for the heart, you're talking about open spaces, and can you move this and baffle that here? And to his credit, we had great outcomes even before I showed up. But, his ability to try to take a really complex, unique heart, which a lot of our patients can have, and figure out a pre-operative plan, I think is difficult. I always struggled with the fact that when I would ask him real details, he clearly had a plan and an idea. But sometimes he was like, well, I need to see for sure when I get in there. And I always felt like, wow. I mean, we need to be doing more. So how can I further what offerings we have to help him and our other surgeons as well? And so that's how we started the 3D Lab interest. And we started out, really with me just getting some trial software, and then we were putting at TCU engineering department with materials that were going to expire to kind of show proof and concept. And then really, through the generous support of the foundation and donors, through the great administrators at Cook Children's, they kind of saw the vision and supported developing the lab. From there, we bought one printer. Now we have three printers. We have surface scanners that I'm sure Dr. Beh will talk about a little bit, maybe some of the things that he's doing with the different technologies we have. We have virtual and augmented reality options. We've expanded in a lot of ways. And so while we started in cardiology, though, really the plan was to make it available to everybody. I'm just a cardiologist, so that was my interest, and that's how we got going.
00:06:26
Host: That's really awesome. So, Dr. Beh, I understand you had an interest and training in the use of 3D printing in surgery before you arrived at Cook Children's. What was it like to have this program and use it in your practice here?
00:06:40
Dr. Beh: I had the fortune of starting here four years ago and meeting Dr. Muyskens. And the interesting thing is that we didn't cross paths in person, but our training was very close, both of us doing some of our training in St Louis. And I had the fortune of doing my training in St Louis, where we started a 3D Lab, when I just started as well. And so I went through that process of building this with one of my mentors in St Louis, and learning and seeing that process of how he used his creativity to go about thinking, how can we use 3D printing to make what we do better? And a lot of what we do in plastic surgery, the success of the surgery that we do comes in gradients. It's not that we operated and everything went well and the patient healed well, but it's also how did it turn out from an esthetic perspective. So every day, and every time, we do a surgery it's a little bit different. Every patient is a little bit different, and the outcome of what you're trying to achieve is a little bit different. And so everything that we do in plastic surgery has that nuance to come along with it. So I lucked out coming in here with Dr. Muyskens, having a lab already set up, and I just brought my concepts of what I trained with in St Louis to build upon that while we are here, and to continue that process of creativity of how can we make patient care even better at each point?
00:08:09
Dr. Muyskens: Yeah, it's been great to have Dr. Beh, and he's really done some amazing stuff with the lab. And it makes Luke Vierkant, who's the lead tech, who helps me do a lot of this stuff in the lab that we create, it's been really exciting just to get outside the cardiology world and do a lot of the cool things in plastics, as well as other fields. And absolutely, I use his talents in the lab as well to talk about what we potentially can do. I bring up a problem with like, hey, we have done this before. Do you think we can modify this somehow to make this even better, to achieve what we want to achieve?
00:08:30
Host: We do so many complex surgeries here, sometimes on very tiny and naturally growing children. What are some of the ones that the 3D Lab plays a role in? And how complex can these models get?
00:08:52
Dr. Beh: In the tiniest of children that we have here in what I do in craniofacial surgery, sometimes we have kids who are born with jaws that are too small. And if their jaws are too small, it’s a condition called micrognathia, associated with a sequence of conditions called Pierre Robin sequence, where the jaw is too small, the tongue gets pushed back, and then the tongue actually gets in the way of breathing. And some of these kids have to be on a ventilator on the first day that they are born because the tongue was getting in a way that they can't breathe. And in these few hour-old kids, we, in the past, have had to get a surgical airway through a tracheostomy, where we create a hole through the neck for them to be able to breathe. But that comes with a whole slew of morbidities and a surgery that we do in pediatric plastic surgery now is something called mandibular distraction, where we actually break the jaw and we slide it forward and help the body create new bone and push that jaw forward, push that tongue forward, so that we can avoid having a tracheostomy in these patients.
And some of these patients are so small that in the past, we would do this almost blind, where we go into the surgery, and then we have to really evaluate the anatomy as we are in there, or just based on CT scans that we already have, and we're trying to reconstruct that in our minds. Now, with this surgery, it's very complex, because we are putting a mandibular distractor device in on a very, very small jaw, we have to place the screws in specific positions after we break the bone to avoid things like tooth buds, a nerve that runs through the jaw itself. And a lot of that can be done now with the 3D Lab and 3D printing, so that I can actually print this physical jaw after the CT scan is done, mark out exactly where these tooth buds are, where the nerve is running through, so that I can plan the surgery itself beforehand, to make my cuts exactly where I want it to go, to put the device in place and put the screws in place exactly where we want it to go, while avoiding all of those things. That way, the decision making is not occurring at the time when the patient is already under anesthesia with the surgical site open, but all of this planning, about 30 minutes to an hour, is all done beforehand, and that way, we can save that time in the operating room and be significantly more accurate with what we do in surgery.
00:11:24
Host: Wow. What a game changer for the babies themselves, but also for the parents and families, because that tracheostomy is a very complicated care.
00:11:33
Dr. Beh: Absolutely.
00:11:34
Host: Wow.
00:11:35
Dr. Muyskens: From a cardiology standpoint, we obviously focus a lot on palliations and really complex congenital heart disease. So as far as when you say small or tiny, you think about the saying, which is roughly true. It's not 100% accurate, but pretty reflective. If you think about your heart is about the size of your fist, right? If you think about a baby's size of the heart and then trying to do open heart surgery and move coronaries and baffle the heart and move great vessels, it's a very complex surgery. And so even if it's a simple palliation, if the anatomy is very unusual, putting a shunt, which is maybe a tube that we put in to provide blood flow to the lungs, can be very atypical, and it can get kinked and twisted and folded, because your typical landmarks and your typical anatomy that we know this works in is a bit different. And so, by 3D printing the heart, we have a much better understanding of those relationships. And we've really moved into a lot of virtual surgical planning, which has been what we've started doing this last year or two, where we really create a virtual shunt to where we want it to go. We can look at the size, the measurement. I can mark spaces on the model exactly where Dr. Tam would want, so he will review it with me. This is something we've started undertaking more recently, so that you can hopefully expedite the surgery, and then we decrease complication rates from the shunts not working properly after surgery.
00:12:53
Dr. Muyskens: As far as the complexity of the models go, a lot of them can be very simple. Like I said, we've actually done a lot of virtual modeling now for a lot of our virtual surgical planning. I mean, in cardiology, at least Dr. Beh's specialty benefits a lot more from more tangible. I think, for cardiac, there's still a big role of that, but we definitely have worked more into the virtual space as well. But as far as printing the models go, we have multiple colors, multiple materials. We actually have something called digital anatomy printing, which is part of the product line that we use here at Cook Children's, and it's actually been engineered to be more tissue-like, whether that's bone or soft tissues, the idea being that it creates a more realistic feel to a surgeon who wants to maybe pre-operatively work and do that surgery ahead of time, like drilling into bone or cutting into tissue.
So, we have that, and then sometimes it's just the heart, or sometimes we really want to know, how does it interact with multiple things inside the chest? So we'll add the airway, the esophagus, lung fields, sometimes the whole rib cage, to say, "Okay, this is a kid who is missing a lung, and the heart is rotated." And so how does that approach, not only the surgery, but the surgical approach for the surgeon who's making the incision, either through a lateral thoracotomy, which is an incision to the side, or from a sternotomy, if the heart is way shifted over, so it gives the surgeons a bit of a better understanding as to “where is the best place I can go from the very beginning?” so that we have less time under anesthesia in the OR with an open chest, which all decreases complications or morbidity.
00:14:17
Dr. Beh: Yeah, and just to respond to that, you were talking about how for me, I like to have more models and things along those lines. And a lot of what we do in craniofacial surgery is not only based on a visual perspective. In the operating room, oftentimes I am cutting into these bones through small incisions because we don't want to leave huge scars in our patients. And some of what we do is actually done blind and only by feel. And, so by having that 3D model beforehand, really helps for us to be able to say, "Hey, exactly where is my saw going to go? How does that feel?" And I will have a sterilizable model that has been made by our lab, brought in and sterilized in the operating room, where I can use the exact saw that, or knife, that I'm going to be using, or saw that I'm going to be using, set it in that model, and being like, okay, now I can see that from my angle, from this trajectory. This is how that is going to feel. Where exactly is that going to go, and does that fit with the plan that I want to achieve? And that allows us to get these very precise cuts done with minimal exposure.
00:15:22
18:44We're always just like, whoa. It's like...
00:15:12
Dr. Muyskens: I think Z's stuff is so cool. I love printing for plastic stuff.
00:15:29
Host: I remember when I first started working here learning the size of your heart's, the size of your fists. And I'm thinking about some of these teeny tiny babies, and you're gonna do heart surgery on that. Wow. So and then you think about now, with you talking about that hadn't really considered how small those little jaws can be. Like...
00:15:46
Dr. Beh: I sometimes bring those models of the baby jaws to show the families, and then also to show our nursing staff as far as education goes as well, because when you see the babies in the NICU their jaws, yes, they are small, but they're also covered with muscle, soft tissue, and they don't realize how small the bone is. And some of those models, they fit probably a quarter of a size of my palm. And the plate that we put on takes up a third of it. And the placement of these small, little micro screws that are going in there, really, they look gigantic. Now, whenever you're comparing them to the size of the baby's mandible.
00:16:23
Host: Wow, cool. Wow, that's just amazing. Dr. Beh, what is the importance of planning in terms of reducing surgical time, particularly when you have very complex or trauma cases? Can you elaborate on what that is?
00:16:37
Dr. Beh: Yeah, in a lot of what we do in plastics and reconstructive surgery is moving tissues, such as bone in this case, whenever we do 3D printing, into a new location, or in the case of trauma, moving them back to where they were supposed to be. And prior to the use of 3D printing, a lot of this was done in the mind's eye. We would get a CT scan based on our clinical examination, we're piecing this together in our head using 2D images and stacking 2D images together. Now with the joys of technology, we're able to create a 3D model on the computer utilizing those things, and then on top of that, print out a physical surgical model. Therefore, all that planning that used to be done in the operating room as we have made our incisions, and are now physically seeing where those bones are in three dimensions, can be done before we even set foot in the operating room.
00:17:34
Dr. Beh: And what this allows us to do is cut out a significant amount of time in the operating room where we are trying to figure out, how do we move these things around? Because the idea have already been done, and it also allows us the opportunity to try new things that maybe we wouldn't have tried before. As far as, "Hey, can I move this bone into this position and successfully get the result that we want?" And the joys of virtual surgical planning is that I'm not physically doing it. I'm just moving it on a computer and then getting to see what that potential bone would look like and say, "Oh, that's great. That's what we're going to do." Or, "You know what? Let's try a different approach, because this is not the most optimal outcome." So in two ways, that cuts down a lot of time. And then the other advantage to it is that we can then try new approaches and actually be more complicated with the type of surgeries that we do to try to increase and improve that outcome. As we talked about in the beginning of the podcast, in plastic surgery, the outcome that we measure is, not only did they heal successfully? But what does it look like?
00:18:44
Dr. Muyskens: Yeah, I think what Z, Dr. Beh, was discussing is really important. That was one of the things that attracted me to the 3D Lab. I tried to explain to people who aren't in the medical field, it's almost like if you took a large house and you just looked at maybe an atypical house, one that's kind of built weird. The rooms are in odd places, right? And you just looked at some pictures online, and you came away with some pictures and then which is all 2D, versus if you lived in that house for a week or two. Now, I pop you in a room and say, you have to get the other side as fast as you can, or to a specific room. If you lived there for a week, you'd be very efficient, because you have spatial awareness, because you've been walking around that house, you understand where the doors are. You understand where things go, versus if you had to just use pictures and you kind of created it, but you're off a little bit. Either way, you're still going to be second-guessing. You're going through it quickly. It's always amazing me about surgeons, because they can do that really well, but I think 3D just makes it even better. When you're talking about children's lives, you're trying to decrease that time those potential complications as much as you can, right? Even if it's a percentage point that's really significant, and that's what gives the 3D printing, the tangible experience you get. Your brain actually gains spatial awareness, and that improves your ability to do tasks
00:19:54
Dr. Beh: Often time in pediatric surgery, we are working in increments of millimeters or half millimeters. And you can imagine that doesn't allow for a lot of error, and 3D printing allows us to get that accuracy and that precision that we want to achieve. And on top of not only knowing that house, taking on the metaphor that you brought up, Dr. Muyskens, is that we can then now plan for what do we want that pathway to look like? And then also change virtually what the house will end up looking like, and then make a plan on how to achieve that route in a new location that wasn't there before. So that's one of the things that we do in trauma, where the face is a very complex 3D structure, and when you have a broken bone of the face, it can move in three dimensions. And how do you go about returning that back to its anatomical location? And in the past, we would have to be able to do this on the fly.
As far as once we get the bones and everything like that loosened up, we have to look at four or five different points of contact on the face, once again, through small incisions to make sure, okay, is the bone exactly where we want it to be? One of the joys of being able to use a 3D model is I can now create this plan, and we can use surgical norms. For example, if there is an unfortunate situation where one side of the face is injured, I can use the mirror image of the unaffected side and actually flip that using the 3D model in the lab to create a model of what potentially we want that injured side of the face to look like. And using that model, once again, bringing that into the operating room, sterilizing it, I can then create a plate that is custom fit for what we want the bone to look like, and then utilize that plate to be able to pull the bone up into that position, instead of having to pull the bone first and then creating a plate to go along with it.
So we've kind of flipped the script on some of the approaches that we have, and by doing so, have been able to achieve great results quickly, because we no longer are putting things together and then stepping back and looking at it once again. But now, all of that has been planned beforehand.
00:22:20
Host: So you've both seen some pretty critical cases. What are the advantages of 3D printing or modeling in reconstructive surgeries?
00:22:27
Dr. Beh: On top of what we've already talked about, a lot of what we do in craniofacial surgery, one of which was cranial synostosis, is going about expanding the skull to provide more room for the brain in patients that have had their sutures or the bones of their skull fuse too early. And 3D modeling allows us to do that for these very complex cases, because there's not only one way to expand the skull. How can we now move these bones in different ways, as we talked about creatively, to not only provide that increased room for the brain, but also to provide an appropriate head shape for the patient. And that head shape can differ and the movement of the bones can differ from patient to patient. And that is one of the greatest advantages of being able to do this with the 3D Lab and with virtual surgical planning, is by moving those bones around and seeing, "Hey, what can we achieve?" And actually getting a little bit more complex with the types of cuts that we can do and how we can jigsaw these bones together so that we can achieve what we want to with minimal gaps in the bones, and while providing more room for the brain and also providing the shape that we want to get to.
00:23:44
Dr. Muyskens: What Dr. Beh touched on, I think the global for me as the director of the 3D Lab is improved outcomes improved or times less complications, morbidity, really, hopefully less cost to the patient and the system as a whole. If your outcome is less than optimal, or in the cardiac world, if we have a shunt that doesn't quite work, or a baffle's too narrowed and it creates too much pressure backup, and that pumping chamber, that ventricle underneath it, is now suffering for that, and we have to go back in and revise it right. That restarts that whole clock. It's another big surgery on a bypass machine for a little, tiny baby or a small child, and then your ICU time restarts. And so that is all cost, complication and recovery time for the family and for the patient and for the system. So really trying to just improve those overall outcomes is the main key.
00:24:31
Dr. Beh: In a lot of what I do, especially in those cranial synostosis cases. I think the bar has just continuously increased now with these technologies and what we are able to do on a surgical side. At first, when this was all done, the goal of the surgery, number one was we need space for the brain, and however you can get it, let's just get it there right. And now, I think the expectation, maybe not for our families, but for the surgeons that do this. And in the long term, outcomes, we are also concerned about the esthetics of what the face is going to look like, what the head is going to look like, and the technology of 3D printing and the 3D Lab and virtual surgical planning has allowed us to kind of hit this secondary goal. Okay, we're treating the problem, but now we're treating the problem in an even more precise way to achieve that secondary goal of making sure that the head looks as good as possible, as normal as possible. That way kids go throughout their childhood and they grow up, and most people don't even know that they underwent a big, major brain surgery and skull surgery when they were first born.
00:25:36
Host: I was just gonna say that sounds like something where you're also impacting their emotional future, because they don't have to deal with being made fun of or something along those lines, or just being afraid to go out for fear of that. So I think that's really amazing.
00:25:51
Dr. Beh: That's absolutely a huge part of what we do in pediatric plastic surgery.
00:25:55
Dr. Muyskens: For sure.
00:25:56
Dr. Beh: For you and I, if we have something that happened to us, we already have our personalities to kind of fall back on. For our pediatric patients and our very young patients, they are still forming that personality, and the social impact of the people around them has a huge impact on that. And so that's absolutely my goal, is to have them have the most normal childhood possible. That way they don't have the issues that might pop up from a social aspect as they continue to get older.
00:26:26
Dr. Muyskens: That's really great. And for cardiac, we know that if you have deep hypothermic arrest, multiple bypass runs, especially as a neonate or a young child, that can have impact both neurologically and your development, has been a big focus in the pediatric cardiac arena is, how do we improve, not just survivability, kind of like Dr. Beh said, if you know, you go back 50 plus years, we want to make these children survive. Now, really, we're trying to switch to making these children thrive, right? And so this shift to, how do we decrease neurologic impact from the surgeries we have to do? It's not like we electively choose these children need these surgeries because their heart is not compatible with long-term survival, or even short-term survival, sometimes. But how do we decrease those number of surgeries? Right? And so by having an accurate surgery that we don't have to go back on pump, that's significant impacts to their learning, their ability to achieve academically, also learning difficulties, which all go back, not only to your academic achievement, but also your social peers, and your ability to keep up academically with your friends, and all those things which are also really important. So ...
00:27:22
Host: Incredible. What other non-critical or non-trauma cases can benefit from this?
00:27:30
Dr. Beh: One thing that we started to do, I think now about a year and a half or so, is using surface scanners with the 3D Lab. One of the conditions that I treat is microtia, and that is kids who are born with misshapen ears or absent ears completely. And for a lot of what I do, whenever we have to recreate an ear, or we have to build a new ear for a patient, is that we want to match the other side that is unaffected. And in the past, how this was done was very rudimentary. I took a piece of paper that you can see through, and I trace the ear on the other side, which is a two dimensional image, and I use that as my example and as my model to create the new ear to be able to match the other side. But I used a little 2D image. But now with the 3D Lab, we're able to use the surface scanner, and we can get a scan on the outside of what the patient's unaffected ear looks like, and using software, flip it and mirror image it so that this can potentially be the exact replica of the ear that they have on the other side, and use that as my model for creating the new ear for that patient. So once again, bringing it up to that next level, no longer are we just putting any sort of ear on the patient, but we want something that matches almost identically to the other side, if we can achieve that.
One of the things that we do here in our lab is creating that model. But if we're looking at the larger industry as a whole, we are potentially able to use that surface scan now, send it off to industry, where they can physically make an implant that is exactly the same as the other ear for us to place in at the time of the surgery as well.
00:29:16
Dr. Muyskens: Yeah, what was really cool is, about four years ago, as I'm reading through things, I'm always trying to think, what can we do with the lab? What can we do? And probably, progress takes time. And so I had some funds that were available, and I purchased that service scanner because I actually read this whole series on micro, microtia, yep, I would say microtia correction.
And so then, now he's using it. It just makes, yeah, it makes it really great. I think there's a lot. I mean, really, the things you can do with 3D printing are pretty endless. I mean, there's a lot of different ways we use it. We've been talking a lot about complex and unique surgeries, which is, I think, where you see the huge benefits, right? And I think are the most emotionally rewarding, too, when you take these kids who have really complex problems and you're able to support the surgeon to have these really cool outcomes. And.
I think if you think about custom orthotics, it's something that we have talked about, right, using a surface scanner. You had a very abnormal limb, let's say, that had been damaged. And maybe custom regular casting doesn't work that great. We could potentially do a Surface Scan and then use that three-dimensional now arm in the virtual space to then create a cast, or something else that we could do. So those are things that we've talked about. I know audiology here is doing fast turnaround custom hearing aids, because the problem with a baby or a really small child is that by the time you do the mold and you ship it off outside of a system, it has to get produced and then get shipped back. Now you get it in six weeks. Well, the child grows really fast, in six weeks. So now your hearing aid no longer fits, and so they're able to actually, then, basically do it in house now, and then, create that mold, print it, and then get it to you within days. That makes a huge difference, right? It makes something that really was not almost feasible before because of commercial turnaround time, is now a real possibility, and has big benefits. I think also education to both staff is really important, and then parents get a lot of benefit, I think, from seeing that.
And we have created the pericardiocentesis training model, which is where you have a heart in the sac around your heart, it's called your pericardium, and it fills up with fluid at times. And so we created a model where we could actually, instead of having to purchase a really expensive model, we could actually put a needle through that sac, fill it with fluid, and then do practice pericardiocentesis. So there's different utilities within the system that we could do that to help as training aids for physicians, or even as an educational component to some of the medical students and things that we have here in the system.
00:31:41
Dr. Beh: Absolutely. And to add on to that, as a cleft surgeon, I work closely with our orthodontic colleagues. And in the dental world, they are also using 3D printing and 3D surface scanners, where, in the past, they were having to get models of your teeth and your palate by putting an impression and getting that impression. Now we're able to do that with a scanner, an intraoral scanner, where they can get high fidelity 3D images, and they're actually creating the retainers, and they're creating the objects that we will put inside the mouth to hold the teeth in that position. And so in cleft cases, one of the things that I work closely with, with the orthodontist, is in our patients with bilateral cleft lip and palates. They have their two front teeth that is connected to a segment of bone we call the pre maxilla, that is a lot of the time out of position from the rest of their dental arch. And in some of these cases, I actually have to surgically break that piece of bone and set it back in line with a dental arch. And using 3D modeling, virtual surgical planning, and then 3D printing, we're actually able to model where exactly we want this piece of bone to go. That way I can do the surgery, and then we can create a, what we call a post operative splint, so a splint for the teeth that is putting the bone and the teeth in its new position. That way I can utilize it at the time of the surgery. I break the bone, I shift it and move it back, but exactly where it goes now I have a splint that fits exactly where the orthodontist wants the teeth. That way I can set it in its place exactly how they would like it and complete the surgery.
00:33:18
Dr. Beh: Wow. Dr. Muyskens, in addition to cardiology and plastic surgery, what other specialties are finding advantages to surgical care here?
00:33:27
Dr. Muyskens: Yeah, great question. I think, by far and away, besides cardiology and craniofacial and plastics, Dr. Beh's division, the division that uses the lab the most is orthopedics. 3D printing has in the medical field has matured more over the last decade. There's interest in all areas, and there's utility in probably to some degree in most areas. But I think besides cardiology, craniofacial plastics, orthopedics, is the other area that's really emerged as a place where they get a lot of benefit. So we do a lot of spine reconstruction models here for patients who have complex spine abnormalities. And with severe scoliosis, Dr. Lamont, who can speak to that, she used the lab quite a bit, but some of the her other colleagues as well. If you look at how long a spine surgery used to take, they're very long surgeries. They're very complex surgeries when you're having to brace with rods a very large portion of the spine that has scoliosis, which is where they have abnormal curvatures of the spinal column, which causes lots of different medical problems. So they want to straighten that spine out. So patients that meet that criteria for surgery in the past, they basically would open up, and then they had to - by feel and experience - figure out where to drill the screws into the vertebral bodies, which is the bodies around your spinal cord. It runs in the middle to secure those rods, and that took a lot of time. Now, both from understanding the 3D prints and then through the utilization of 3D pre-created drilling guides.
So now you can essentially make the 3D model of the spine and then, through engineering, you can create a guide that sits on top of the bone and fits it flush. And then within that, there's a hole that allows you to then predetermine what is the optimal screw position. So now, instead of trying to figure that out and hope that you're obviously not either in or out of that vertebral body, that bony area, because if you're inside, it's the spinal cord that's dangerous place to be. And if you're outside, you're still in important tissues. And I'm probably over simplifying this. I'm not an orthopedic surgeon, so blood vessels, exactly. Blood vessels, lots of importance you know. And so, now, they're able to put that, and if they know once they fit that, that it will be just in the bone in the right spot. So they're cutting spine surgeries in half time-wise. And these are day long, very long surgeries, and oftentimes have quite a bit of blood loss. They're big surgeries. And so they're able to really work on that.
There's lots of other applications. We've done some pelvis reconstructions. Bony tumor remodeling for excision or cutting out of those tumors. And there's also areas where they make bone incisions for different reasons. It calls osteotomy guides that you can use 3D modeling for to create those guides. So once they open and they expose the bone, they're able to put the guide on and make those incisions quickly.
00:36:12
Dr. Beh: Absolutely. And I can also imagine, you know, I'm not a spine surgeon either, but I do know that there's a lot of X rays that are done intraoperatively, and I can imagine that by having those 3D guides, maybe they do not have to rely on as many X rays, reducing radiation exposure to our pediatric patients.
00:36:29
Host: Of course, something that budget people always want to know is, what are the financial benefits of having an in-house, 3D Lab, both to the health care system and to the families?
00:36:39
Dr. Muyskens: That is a great question. I get that question all the time as the one who's had the joy of developing the 3D Lab. Let's start with what commercial printing is, right? I think there's always going to be a utility for industry printing, and they definitely are able to put a lot of energy and finances towards projects that advance care and what Dr. Beh does. Dr. Lamont does a lot of things that both an in-house lab may do or may not do, are out there, but Dr. Beh can speak to this, probably better than me. But in my understanding in talking with surgeons, oftentimes the collaboration, depending on the company, can be not perfect. Obviously, sometimes there's communication barriers, right? Dr. Beh is busy. He’s here caring for children all day. We are a clinically care driven institution trying to perform high quality outcomes for children. And so Dr. Beh is in the operating room much of the time while working. And so having those times where you can have easy communication, so you can get a good understanding, trying to set up zoom calls with industry that may be in Germany or other parts of the world or in different time zones within the US, right? And then really dependency, sometimes on external expertise, because what's being produced is there. And while Dr. Beh, Dr. Lamont, or whatever, surgeon can then look on Zoom call and have some interaction, or sometimes they can, they'll get files and they can review those, it's still not a hands-on experience, because the industry is really producing those. And then turnaround times has been one of the biggest things.
We mentioned a little bit before, and this is what I've heard from my surgical colleagues. They may need something done in the next week or two, because, if it's a trauma case or something more important, they have their own production timelines. They oftentimes can move pretty fast. And there's also shipping timelines. If it is a product that's being produced, let's say, in Germany but it's going to take a little while to get here, and then costs right? Those infrastructures do incur quite a bit of cost to start those companies and do those things. And so external printing oftentimes can be quite expensive. And so if you look at our model here at Cook Children's, we have a different model. When we created this, I realized being in this system for at that point, six years, now I've been here 16 years, that our surgeons are busy, they don't have a lot of office time, and so we have to really kind of create a concierge level of service, where the lab is open and accessible, the surgeon can pop in and work with our staff to create that model, to be part of that creation process, and really part of the proofing concept. So if we print something and it comes to Dr. Beh's desk. then if it's not exactly what he expected, it's easy for us to go back and rework that. And so we have multiple checkpoints that we try to click on as we go through both the initial process of creating the model a virtual kind of proofing, if that's what they want, because say, they work primarily in Prosper. We can create that ability to review the model, either by virtual reality or just in on a computer screen to check that as quickly as possible.
Of us that are here on site, they stop by. I know Dr. Beh comes to the lab, not infrequently, and then production is hours, and delivery can be minutes versus days and weeks in the commercial time zone. And so… and if you're talking about improving outcomes, time can be really important. And a lot of those projects that we have been able to move internally is more efficient, both from a “What we've described”, but also just from a “cost standpoint,” that we don't have to have all the huge overhead that a lot of industry does, because they have maybe more of an expansive and more complex range of things that they can do. You incur that cost, regardless of what you're making.
00:40:03
Dr. Beh: Yeah, and I do have to give a shout out to Luke, because the time factor here in our trauma patients is a huge factor that we're able to utilize a 3D Lab that's in house to be able to have this expediency, because trauma doesn't have a time frame of when it happens. I can remember definitely a few times where I'm calling Luke up because we have an unfortunate patient that comes in on a Friday afternoon and I want to operate on them next week. And if I'm trying to go through industry, they don't work beyond those Monday to Friday hours. It's not a weekend hour, or something along those lines, but having the ability to meet with Luke and come up with a plan of what our surgical model is going to look like, have him start that print Friday night or sometimes Saturday morning, and have it available for me on Monday is an amazing feat that we have for our lab.
And that has been an absolute favorite of mine, having the ability to do, as Dr. Muyskens had mentioned, this is concierge level of care that we get from our 3D Lab. And on top of that, working with Luke time and time again, he is understanding what I want to achieve. And sometimes, when I go through industry, for a particular case, I might get the same person on the other end, on their lab that has worked with me before, or I might get somebody that's completely brand new. And while they have seen a little bit of what we've done before, they have not gone through that process before. And now that takes extra amount of time getting that individual up to speed with what I'm looking for. And then the quality of what we have on the other end can vary as well, and having that consistency in our in house lab is something that is wonderful to have, and it's very unique. I do not think that a lot of hospital systems have this capability and this availability.
00:41:55
Dr. Muyskens: It really makes like kind of part of the team, right? And correct me if I'm wrong. nut as a surgeon, when you learn a technique, you learn kind of a board certified or a approved approach that we know works well, but over time, you develop your own unique approaches. How you want to do things. Every surgeon is a little bit different, which is why I know a surgeon sometimes will have different tools, unique tools, that they like. And so, like you said, he learns the way you perform surgery and the way you want to approach a problem, and therefore you guys are now working together versus just purchasing a product off the shelf, essentially.
00:42:28
Dr. Beh: Absolutely. And the nice part to that, I get very real feedback as well. It's like, "hey, we tried to do this last time on the print side and this is some of the problems that we ran into. Is there something that we can do to try to improve that?" So absolutely, the 3D Lab is part of the medical team that we have to be able to provide the best outcomes that we can get for the patients that we have here.
00:42:49
Dr. Muyskens: If you look at additional costs, like we mentioned before, I mean, it's improving outcomes, if you look at OR times, I mean, ORs are not cheap, right? They're expensive to run, and so if you're cutting time in and or you're saving the patients in the system, because that cost gets passed along, you're saving that cost for families as well. And then, in just addition to the other costs from more surgeries, more complications, things like that, which is not just the financial cost, but emotional costs. So there's a lot of cost savings in 3D printing. Some of it's not always easy to quantify, which makes it challenging when people are developing 3D Labs, but I think everybody, especially in the current era, has started to recognize the tangible benefits, both financially and the cost to families and patients emotionally and from a recovery and a health standpoint, that makes 3D printing beneficial.
00:43:35
Host: Well, it sounds to me like too when you bring in a trauma patient, that's like emergency room stuff, right? And they're coming in, and the longer they have to wait, the longer they're sort of suffering. So it really sort of cuts down on that too, correct?
00:43:48
Dr. Beh: Absolutely. The ability to get to it in an expeditious manner and not say, you know what I'm gonna go through industry, have this printed out. I'll be able to get through this in two weeks, where, on top of the fact that the patient's waiting for a longer period of time, it makes the surgery harder, because now we're working through scar tissue instead of a freshly injured bed is something that we have to keep in mind in a lot of what we do in plastic surgery. The time element for a trauma case is important, because if we wait the bones -- and in kids they'll heal so quickly, and now, instead of going through an area where there wasn't the injury, because they've already started to heal and make the outcomes actually worse. And so we have to keep all those things in mind and in response to what you were saying, Dr. Muyskens, is in plastic surgery, compared to other surgical specialties, there's not one way to do surgery. There is multitude of different ways to go about it, and a lot of that nuance is not only preference per the surgeon, but also specific to the injury that the patient might have, the condition that the patient might have. And it can be as simple as hey, the bone broke a centimeter over in a little different position. Now my approach is going to be a little bit different. And having those nuances and then working with somebody who starts to pick up some of those nuances is very helpful in saving time in the planning process, and then also making sure that we're able to achieve the results that we want to.
00:45:19
Dr. Muyskens: I didn't really think about that. As you know, in cardiology, there's variability from patient to patient, but a lot of the bread and butter of what we do have fairly predictable developmental abnormalities, right? But for you, when a bone breaks, can break in a million different way, absolutely, and you gotta figure out how to reconstruct it in a million different ways.
00:45:38
Dr. Beh: And a lot of what we do in plastic surgery is utilizing the tissues that are already there for reconstruction, and sometimes those tissues are not there, and you have to get creative as far as, how do you bring that tissue into that area? We talked about microtia before. There's a whole staging system for microtia where the ear is completely absent, to where all the structures might be there, they might just be malformed or smaller. And in each one of those stages, your approach can be different. And even in a person without microtia, an ear is different from an ear is different from an ear, right?
00:45:41
Dr. Muyskens: Yeah, I didn't think about that. That's great.
00:45:42
Dr. Beh: Yeah.
00:45:43
Host: So beyond being a planning tool for surgeons, I can only imagine how useful these models can be in helping parents and kids understand what the issue is and how it's gonna be fixed, and even training medical teams. What's that like?
00:45:45
Dr. Muyskens: Yeah, I'll start first then I'll listen what the surgeon says who has even more experience with that interaction than me, but I think from my interaction in the cardiology world with our patients definitely makes a big difference, especially in patients who have really complex hearts. You know, one of the side tools that we try to figure out when we're going through pediatric cardiology fellowship is how well we can draw because a lot of what we do when we meet a patient for the first time is try to draw their anatomy. Like I said, even though you might… say, a classic one that we see is something called tetralogy of Fallot. It's composed of a big hole between the bottom chambers, a very small pulmonary valve, which is the valve that lets blood go out to the lungs to get oxygen and the aortic shift in the right side is often very hypertrophied. But there's a huge variation on that from really, where it's an almost normal heart and requires very little manipulation, to one where the pulmonaries Don't even develop normally and they're just strings coming off of the aorta. So it can be very big variety. And so, when we meet those patients for the first time, those parents, and we're having to try to draw some of these things out, it's very challenging. Some of us draw, some of us try to find diagrams. But to somewhat like Dr. Beh had said, even in the cardiac world, there's a fair number of variations. So you're usually manipulating, trying to manipulate this and trying to get this information to the families and really complex heart disease. I mean, I love to draw. I wanted to be an artist, but my father said no, so I went on this path instead. And you can't find there's no drawing. So trying to articulate to the family, here's what's going on with your child's heart when, A, they don't have a frame of reference, oftentimes the way a normal heart ism so you kind of start there. And then why their child's surgery is gonna be more complex and maybe more high risk than another child's is really difficult when they have no real bearing to try to ... and you can't even draw it for them or try to get them to understand it.
So, you know, having that ability to print a model or create a virtual... you know, we sometimes in the past, have done augmented reality with the families to really show them. This is what your child's heart looks like, and this is why. Here's a normal heart and here's your child's heart. You can see how things are upstairs, downstairs, left to right. Everything is switched around, and now we've got to figure out a way to palliate your child too, so that they can thrive and go and have fun and do all the things that you want as a kid. And so I think that's really important, because the other thing that I've noticed over time is that it helps remove the disconnect, I think, as a care provider and a parent, right? If you think about from a parent standpoint, you're trusting this person, a surgeon or even just a cardiologist like myself, to take your child on a journey that's going to make them as happy and healthy as possible, right? Oftentimes with no understanding.
Dr. Muyskens: So it's like when you have someone build your house, you trust that the engineer did it right, and you hope that the builder is going to do it right, right? This is your child. This isn't a house, right? And so you're having to go along. And the more challenging these really complex cases, you can see that it's difficult for the medical team to articulate, and it's difficult for the family to understand. And then what does everybody do when they don't understand something? They get online and you go start Googling stuff, right? And there's definitely nothing about this on the website, but you'll find somebody who says something, and that creates, I think, more angst, oftentimes, more distrust, more questions. And so if you're able to then bridge that gap and have the surgeon saying, Here, here's your child's heart, or problem for other specialties, right? This is why it's so complex. This is why it's different. And there's not a template for this, but this is what we think we can do. Let's walk through as a family and figure out this as a medical team and a family. How do we want to care for your child? I think that really helps connect those two pieces in really unusual cases, for sure.
00:49:59
Dr. Beh: Yeah, and for me, patient specific models, for families, I think, have a significantly bigger impact. Before we are able to do 3D printing of patient specific models in a very expeditious manner, we will have models, or, as Dr. Muyskens says, pictures that we've drawn, or diagrams, and we try to show families that, but when it's a generic thing that was just drawn up, or something that we found on the internet, or a diagram that is a generic diagram, it doesn't have the same impact for the families. And having to say, well, this picture shows it this way, but when I'm planning my surgery, this is actually how it's going to be different from the picture. It doesn't have a very good impact, and doesn't help our families to streamline exactly how we're going to approach this particular case.
And now, when I have a 3D model, sometimes of just a CT scan that we modeled on the computer, and we're able to have them see it in three dimensions, to be able to rotate it, and then taking that to the next level, showing them, hey, this is exactly what my plan is. The hour that I spent creating this surgical plan in virtual surgical planning. Now, this is how I plan on moving the bones, and this is where they're ultimately going to end up. And we print a model of that, and they can physically hold that in their hands and look at it from all different trajectories, I think really helps them to understand the significance of what we're doing and really understand what their child is going to be going through. And on top of that, have an idea of what the outcome is going to look like before the surgery actually happens.
00:51:35
Dr. Muyskens: Yeah.
00:51:36
Dr. Beh: And I believe that it has a huge, very significant impact.
00:51:39
Dr. Muyskens: Yeah, because in our patients, what Dr. Beh does oftentimes, not always I'm sure, but oftentimes it's very visual. For us. It's just inside your chest, right? Their kid looks great. They're like, Whoa, that. My kid looks awesome. Maybe he's a little bit bluish, maybe, depending on the problem, or maybe he's not. Umm, like, I don't really understand, because he looks like a normal, healthy kid to me, right? Or normal, healthy baby. And so oftentimes they'll ask to see images. But reading an echo takes us years, as cardiologists, to be able to read an echo with tons of two dimensional clips that you have to then reconstruct in your brain what the heart looks like. And it takes you years to understand how to do that. And radiologists the same thing, CT scans, some of the 3D reconstructions from CT, CMR, cardiac MRI that we can do helps with that, but still not quite the same. So ... it's almost like reaching in and pulling the heart out and giving it to their parents and saying, "This is what's going on in there." And they're like, "Ah! Well, it kind of makes sense." And you can match up with their symptoms and what's going on. And I go, this is starting to click now, whereas before, they're like, I just came in for, like, a simple problem, and now you're telling me my baby has this really significant problem with their heart, and I have to have this huge surgery, and it's very scary.
00:52:41
Dr. Beh: And from an education standpoint for our families and then also the nursing staff that take care of our patients, we talked about manipulative distraction earlier on in this podcast. That is something that we rely on our nurses, and we also rely on families sometimes to perform those distractions, because multiple times a day, we ask them to take a literal screwdriver, attach it to the device that we have placed and have them turn it to be able to shift and to move the bones. And we ask our nurses to do this. And we ask our families, sometimes, when they go home, to do this. And by being able to provide them a model of their child and showing that when you turned a screwdriver, this is what is happening on the inside. The plates are sliding apart, and the bone that we had cut is now sliding apart and moving and showing them that this is how the device works. This is what is actually happening to your child. It really helps them solidify, "Hey, this is what I need to do. This is why I need to stay on that schedule." And if there's something that doesn't feel quite right, you have an idea of, oh, well, you know, this is an issue that I have to contact Dr. Beh about because something's not feeling quite right. And that has a huge impact, not only for our patient's family but, also, I get responses from our nurses saying,"I love it when you bring these models in and you're talking with families about it." They love to sit behind my shoulder and also listen in, because that's the patient that they are taking care of, and I'm asking them to do these distractions at the bedside for the babies.
00:54:90
Host: Wow, this is just so incredible. So in researching this topic, there's a whole new realm of possibilities that are being explored, such as fetal surgeries, which leads to one of my favorite questions, looking ahead, where do you see this program and its applications in the future?
00:54:26
Dr. Muyskens: That's another great question. I think we have lots of ideas, lots of places we want to go, and some places we're already continuing to go. So I think we have definitely created, with our lab, a solid ground floor. Maybe our first couple floors. Maybe that's not a fair statement. Where we're able to do a lot of really cool things with what we have, I think when we look at where we want to go as a program, we really want to expand more into much more complex pre-surgical modeling or planning. A lot of that requires engineering capabilities. So we're in the process now of working through that and getting ready to recruit an engineer for the 3D Lab, which will be a fantastic addition. And we hope to have someone by the spring to be included in the lab, or at least by the summer of 2026.
From a cardiac standpoint, which I can speak to, I think that one of the areas that we're really interested in is, or I'm specifically interested in, is computational fluid dynamics. So it’s called CFD. Really what you can use this application all kinds of parts of our world, and the engineers use it all the time, but what we can do in certain aspects, from a heart standpoint, is say, what is the optimal surgical palliation for this patient at this point in time? So going back to my discussion about the patients who have tetralogy of Fallot, oftentimes they have almost complete or complete pulmonary atresia, meaning that the pulmonary valve never formed. It's just a dead end. And so essentially, where there was supposed to be a valve, there's a piece of tissue so the heart can't connect to the lungs, and the lung vessels, which are sometimes sitting there, can't connect to the heart, and so they depend on another vessel called a PDA, or pain ductus arteriosus, which provides blood from the aorta to the lungs, which keeps your child alive.
So we often can't just do a complete repair right at birth be - because those surgeries have less optimal outcomes sometimes. So we can't do those surgeries at birth oftentimes, because the outcomes are not as good as we would like them to be. So we find what we call palliation, a way to bridge a gap until the child or baby's bigger, and then we can do initial repair.
One option that we entertain nowadays is PDA stenting. So we model all of our PDAs tissues and we look at whether they are viable to put a stent in. The reason we started doing this versus a classic BT shunt, what’s called Blalock-Taussig-Thomas shunt, actually, BTT shunt, is the classic where we put a Gortex tube between the aorta and the lungs, because that PDA, we can keep it open with special medication called prostaglandins, which mom produces. But after birth, we give it to you artificial version. But once you turn that off, it goes away, and then there's no blood flow to your lungs. So we have to find a way to create a stable source of blood flow to your lungs so we can ... classically, we always used to do BT shots or paste these tubes, and then we would just get rid of or ligate that PDA, and you could go home that way. It's a great surgery. It's been around for a very long time. Was clearly the first, probably surgical intervention for blue babies, created long, long time ago. If you're interested, a side note, Something the Lord Made is the movie. It's a really interesting movie, if you're interested in looking at the whole concept and creation of the BTT shunt.
But there are problems with ACH and kink. Like we talked about before it can clot. Oftentimes you get unilateral meaning one side blood vessels grow better than the other. And we looked at long-term outcomes. We know having equal growth of the pulmonary arteries, which are the blood vessels that feed the lungs, is really important. So we started moving towards PDA stenting now, because we actually see that they get better growth of both branch pulmonary arteries. But there's potential problems with that. It's not an easy as soon as you oftentimes go to a diploid, that stent, that PDA tissue is, it's supposed to contract normally, so it spasms down and completely closes off. So it's a they have to move very quickly, which is why we want to have a predefined plan for the exact stent where the markers are, and make sure that it's actually a viable anatomy, so that we don't put that patient at risk. Sometimes now, we're also entertaining, which we didn't used to before, is putting a stent in the RV outflow track, which is the connection between the heart and the pulmonary arteries, if there's still a small opening there, and that actually has really good outcomes, and that has better pa growth. So we're looking at, how do we optimize so the only way we know that is, how does blood flow?
And so by looking at doing computational fluid dynamics, looking at, hey, this is my anatomy. I have a 3D model. I understand basic pressures and information, I can put that into a computer system, and it will basically tell me, what is my flow going to look like, what are my shear forces? What's my risk of clotting, some of those things. It's also found a lot of utility in patients who have really complex anatomy, who have a complex three stage palliation called a Fontan palliation, for patients who typically have only one viable pumping chamber, and we have to reconstruct and because they replumb their cardiovascular system, they often run into problems of unequal blood flow to the lungs that can sometimes get other abnormalities in those lungs that cause their oxygen saturations To drop. And so trying to understand, how does that blood flow, and then how do we do it? So that was one of my initial interests when I started the cardiac MRI program. And around the time I started the lab was doing four dimensional flow.
So now we can actually look at the streaming of the blood flow as it currently sits. Then how do we manipulate that? Right? I can have ideas, and I can try to create these different baffles, or how would we revise that for the surgeon? Some of the stuff they come up with their surgeons gonna look at me and say, There's no way I can do that, right? But between the different approaches, and then using computational fluid dynamics from the data that we have, both from Cath and from cardiac MRI or CT and modeling of the heart, we can then say, Okay, well, this is actually gonna get better outcomes. We're gonna get rid of those problems in that lung, because we're gonna redirect blood flow from the liver, and that's gonna give us less problems, less AV malformations in that lung, improve the patient's saturations, improve their long term outcome, survivability, all those things. So that's an area that we're looking to work on. And then, as we now develop a heart transplant program here at Cook Children's over the next few years, we're really excited about big endeavor, about.
We're super excited, is that classic heart transplant criteria really is eligibility for a child is based on their weight. And we know that our children, oftentimes, especially if they're older, and they've had a really dilated heart for a really long time, that the size heart that their chest can actually accommodate is much bigger than a child who had just an acute problem and their heart stopped working, and then they needed a transplant. And so you're limiting the donor pool and the potential for that child to get a heart, if you are only going by those criteria. So there's a lot more being published. Cincinnati Children's Hospital has been a big publisher of this data, looking at volumetric criteria by doing 3D modeling and also virtual placement of these ventricular assist devices, which are mechanical pumps for the heart that are failing, they're very invasive, and they have to fit inside your chest cavity. And chest cavities aren't all the same, and heart sizes aren't all the same. So is it going to fit? How does it fit? You can virtually model all of that and make sure that that ventricular assist device or VAD is going to be optimal for that child. And so those are some of the things that we would like to undertake as we move forward with some engineering expertise within the cardiology division. I know Dr. Beh and Dr. Lamont have their own data. So let Dr. Beh talk about some of the things he's interested in.
00:01:10
Dr. Beh: Yeah, I think that the sky is the limit. And the only limiting factor that we will have is what is our creativity of how can we apply this to the patients that we have already a lot of what we do in craniofacial and plastic surgery currently is boney modeling, because that tends to be more stable, and you can get good images from that from a CT scan and high fidelity images. But there's a lot coming up in the world of MRI and a lot more dynamic type imaging, and I think that it just takes somebody to have a good, creative idea of how to apply that in that 3D Lab to refine our outcomes even more, as we talked about, we are going well beyond just having a patient heal, having them survive, to now thinking years down the line, how can we improve our outcomes to the point where people didn't know if they had a problem in the first place?
That is our goal, and I think that is where I would love for our lab to be super excited about having an engineer, because that is also yet another person that's part of our medical team that we can bounce some of these ideas off of, saying, "Hey, I have this particular problem, and it's popping up time and time again. Let's put our heads together. How can we figure this out?" And for Cook Children's, I think we are a very unique institution in that we are not directly associated with an academic facility, but we are taking care of the same level of acuity as the best hospitals in the rest of the country, and we also have a very significantly large volume of patients that come here, and through that comes a lot of clinical expertise and the opportunity to be a leader in this surgical field or in the medical field for our pediatric patients. And I would love for us to help harness utilizing our 3D Lab to be able to bring us to that level and to be able to share our expertise with the rest of the country and the rest of the world as well.
When I came up through the training 16 years ago, 3D printing was kind of a novel idea. And then when Dr. Beh trained, it was part of his training, right? We look at all the cool things we're doing now, thanks to Dr. Beh being here, and you think about other younger surgeons coming up, right, who are using this or have ideas, really, the sky's the limit as we have the talent, and we have such great surgeons, such great clinicians. I agree with Dr. Beh, we're a very unique institution. I love working here. So as we wrap up, is there anything else you want to add?
I think I think I just want to add on to the last question that we had, which was, where do we see this future? As Dr. Muyskens had mentioned, I trained with 3D printing. It was still relatively novel at that time, and so the lab was being built up, but I think in my surgical training that 3D printing and 3D modeling played a huge role in me truly understanding the three dimensional anatomy that I'm operating on. A lot of what my predecessors used to be able to just construct in their mind as a trainee baffled me at times. And when you're doing a surgery such as cranial complex craniofacial surgery, where some of this is done by feel and where, usually it's one surgeon that's able to get their hands in there or have the best view. It was hard to learn. And you have to be in multiple cases. You have to study a lot. And one of the main things that I was able to study is these 3D models, and being physically able to hold a patient's model that you're going to operate on and see how we're going to approach that particular case, and then go to the operating room and perform that surgery is such a valuable learning experience of being able to do this and being able to do this safely in training as well.
And so I do think that we have that capability of doing so here as well, in the form of education, not only for our families our nurses, but training the next generation of surgeons and training the next generations of physicians to be able to continue to build as we have built on the shoulders of giants that came before us.
00:05:18
Dr. Muyskens: Yeah, I think for me, when I think about the 3D Lab and the reason I get so excited about all the stuff that Dr. Beh does is it validates what we're trying to do. Our take home cultural message is we're trying to provide exceptional care. If you think about a roof, is that exceptional care? What is it built upon? Right? Exceptional care just doesn't come because you say it in a motto. It comes through the awesome surgeons that we have and the clinical expertise and all the staff that we have here, nurses to everybody that helps provide that care. But really, there's three pillars. I think there's physician experience, awesome clinical expertise, right? There's evidence based medicine. We're doing what the evidence says is the best. And then I think aligning what you're doing with patients and their values are really important. Well, what's the foundation? First, you have to actually diagnose them with the right problem, right? Otherwise it doesn't mean anything. And so especially in patients who have really complex problems or unique problems, we use all this two dimensional imaging, but if it doesn't really fully articulate what the problem is, because a you haven't seen this variety before, or it's just really complex, and there's just some shortcomings to the medical imaging that we have now. Then that foundation gets weak.
If it's something they really haven't seen before, then there's no evidence based medicine for that. And physician experience with caring for that, even as a non-surgeon, it's kind of well, how do I manage this patient? It gets a little more difficult. And then, if you can't articulate what's going on, like we talked about before with the family, so that you can align your values, then that whole infrastructure starts to become a little wobbly. I think, by taking the data we have and making a better version of that, really having 3D printing, we're able to then take that information. I can give this model to my surgeon, to Dr. Bey, to Dr. Tam, to Dr. Lamont, to whoever in our institution, and they can then say, well, now I have understanding, right? I can come up with a plan. So I may not have done this surgery 65 times, but I have a really good understanding of the anatomy now, because I have this new information. So your foundation is shored up. You're helping improve the surgeon's ability to manage that problem. You're able to then shore up really, that patient's values and align it to what we're doing, right? Which then helps keeps that support.
We're really continuing to provide exceptional care because from a parent, care, because from a parent's standpoint, they don't care that their child's problem is unique and difficult for you. They just want the best for their child, and they expect us to do everything we have in our ability to help their child have the outcome. And like Dr. Beh said, we do everything here. We have such a robust system, and we care for really complex patients, it really is a testament to the families and the communities that we serve, that the system has invested and continues to invest in this program so we can actually improve outcomes care for the patients we already have that are really complex, and improve those outcomes as well.
In fact, I think 3D imaging really is becoming more of a standard of care, and I'm just excited that we have the opportunity to provide those specialty services to our families.
01:08:02
Dr. Beh: Yeah, and to add on to that model surgery, you brought up a good point is that we see things that are rare, and sometimes the treatment for that rare problem might be a surgery that you do once a year, and with that, you want to ensure that everything goes as smoothly as possible. So one of the things that I have done here is had our 3D Lab build a model or print a model, and I have gone to the OR with that model and have physically performed model surgery on those models so that I can cut the bones exactly where I want them to be ... see and go through the process of doing the surgery once, twice, before I actually operate on the patient.
01:08:40
Host: Wow, that's amazing. That's just amazing. What may be on the minds of some of our other health care listeners out there is what role might AI play in the future?
There's definitely an AI component from a 3D Lab reconstruction standpoint. I am not an expert in the field. I can tell you from my experience, AI with really great data speeds model creation exponentially. However, anybody who's been in medicine long enough knows, especially when you're working with kids who maybe are moving or wiggling around the table, or even sometimes it's based on what they already have in their body, implants, things like that. Oftentimes we get artifact, and there's also just inherent artifact that you get in cardiac MRI, for example, from how the blood flows, there's areas that are void. And the way model technology works is it's looking for specific intensities within specific pixels of the imaging that we use to identify what I give it guidelines for. And the AI can deal with that and overcome with that. But oftentimes there is significant artifact where then you really have to have an understanding of the anatomy. You can see through some of the artifact that you know exists, because it's the way the heart is, and so it makes sense to your brain. AI may be able to overcome that over time. Right now, we use a lot of AI in some of our post processing reading platforms.
01:09:59
Dr. Muyskens: Some of it's really good, and some of it is not. It actually works against me, sometimes from a timeline wise. So AI's got a role in everything. If you think about statements, talk about how physicians are gonna be replaced, or care models can be replaced. Reality is, if you're sick, you want family. You want someone who understands you and you feel cared for. I don't want a robot coming in a room and caring for me. I would rather take a chance that this guy gonna get wrong a little bit, but at least he cares about me, right and you have that human because you don't feel alone. And so I think that's where AI, hopefully can help us be much better at what we do in some faculty, but it's never gonna replace people in medicine, not people that are patient facing so ...
01:10:36
Dr. Beh: For sure
01:10:37
Host: Thank you both for being here and really sharing about the impact of the 3D Lab has on improving the care for kids. It's incredible. And this has been a really, really exciting podcast. And thank you for sharing all of your wisdom and knowledge and experience.
01:10:52
Dr. Beh: Thanks for the invite. It's been great. Thank you. I love having that conversation with both you, Jan and Dr. Muyskens.
01:10:58
Host: For our listeners, if you'd like to make a referral visit the 3D Lab on our website, you will find more information about research, plastic surgery, and cardiology on our website at Cook Children's dot org. You can also access clinical pathways on the health professionals section of the website, and while you're there, sign up for our Doc Talk newsletter. Want more Doc Talk? Get our latest episodes delivered directly to your inbox when you subscribe to our Cook Children's Doc Talk podcast from your favorite podcast provider, and thank you for listening.
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