Flexible and comprehensive patient-specific mitral valve silicone models with chordae tendineae made from 3D-printable molds

  • Sandy EngelhardtEmail author
  • Simon Sauerzapf
  • Bernhard Preim
  • Matthias Karck
  • Ivo Wolf
  • Raffaele De Simone
Original Article



Given the multitude of challenges surgeons face during mitral valve repair surgery, they should have a high confidence in handling of instruments and in the application of surgical techniques before they enter the operating room. Unfortunately, opportunities for surgical training of minimally invasive repair are very limited, leading to a situation where most surgeons undergo a steep learning curve while operating the first patients.


In order to provide a realistic tool for surgical training, a commercial simulator was augmented by flexible patient-specific mitral valve replica. In an elaborated production pipeline, finalized after many optimization cycles, models were segmented from 3D ultrasound and then 3D-printable molds were computed automatically and printed in rigid material, the lower part being water-soluble. After silicone injection, the silicone model was dissolved from the mold and anchored in the simulator.


To our knowledge, our models are the first to comprise the full mitral valve apparatus, i.e., the annulus, leaflets, chordae tendineae and papillary muscles. Nine different valve molds were automatically created according to the proposed workflow (seven prolapsed valves and two valves with functional mitral insufficiency). From these mold geometries, 16 replica were manufactured. A material test revealed that EcoflexTM 00-30 is the most suitable material for leaflet-mimicking tissue out of seven mixtures. Production time was around 36 h per valve. Twelve surgeons performed various surgical techniques, e.g., annuloplasty, neo-chordae implantation, triangular leaflet resection, and assessed the realism of the valves very positively.


The standardized production process guarantees a high anatomical recapitulation of the silicone valves to the segmented models and the ultrasound data. Models are of unprecedented quality and maintain a high realism during haptic interaction with instruments and suture material.


3D printing Flexible mitral valve Surgical training simulator 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

Supplementary material 1 (mp4 42338 KB)


  1. 1.
    Engelhardt S, De Simone R, Full PM, Karck M, Wolf I (2018) Improving surgical training phantoms by hyperrealism: deep unpaired image-to-image translation from real surgeries. In: Frangi A, Schnabel J, Davatzikos C, Alberola-López C, Fichtinger G (eds) Medical image computing and computer assisted intervention—MICCAI 2018. MICCAI 2018. Lecture Notes in Computer Science, vol 11070. Springer, Cham.
  2. 2.
    Engelhardt S, Lichtenberg N, Al-Maisary S, De Simone R, Rauch H, Roggenbach J, Müller S, Karck M, Meinzer HP, Wolf I (2015) Towards automatic assessment of the mitral valve coaptation zone from 4D ultrasound. In: van Assen H, Bovendeerd P, Delhaas T (eds) Functional imaging and modeling of the heart. FIMH 2015. Lecture Notes in Computer Science, vol 9126. Springer, Cham, pp 137–145.
  3. 3.
    Engelhardt S, Sauerzapf S, Al-Maisary S, Karck M, Preim B, Wolf I, De Simone R (2018) Elastic mitral valve silicone replica made from 3D-printable molds offer advanced surgical training. In: Maier A, Deserno T, Handels H, Maier-Hein K, Palm C, Tolxdorff T (eds) Bildverarbeitung für die Medizin 2018. Informatik aktuell. Springer Vieweg, Berlin, Heidelberg.
  4. 4.
    Engelhardt S, Sauerzapf S, Brcic A, Karck M, Wolf I, De Simone R (2019) Replicated mitral valve models from real patients offer training opportunities for minimally invasive mitral valve repair. Interact CardioVasc Thoracic Surg.
  5. 5.
    Engelhardt S, Wolf I, Al-Maisary S, Schmidt H, Meinzer HP, Karck M, De Simone R (2016) Intraoperative quantitative mitral valve analysis using optical tracking technology. Ann Thorac Surg 101(5):1950–6CrossRefPubMedGoogle Scholar
  6. 6.
    Ginty O, Moore J, Peters T, Bainbridge D (2018) Modeling patient-specific deformable mitral valves. J Cardiothorac Vasc Anesth 32(3):1368–1373CrossRefPubMedGoogle Scholar
  7. 7.
    Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW (2013) Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation 128(5):483–491CrossRefPubMedGoogle Scholar
  8. 8.
    Ilina A, Lasso A, Jolley MA, Wohler B, Nguyen A, Scanlan A, Baum Z, McGowan F, Fichtinger G (2017) Patient-specific pediatric silicone heart valve models based on 3D ultrasound. In: Proceeding of the SPIE 10135, p 1013516Google Scholar
  9. 9.
    Kenngott HG, Wünscher JJ, Wagner M, Preukschas A, Wekerle AL, Neher P, Suwelack S, Speidel S, Nickel F, Oladokun D, Maier-Hein L, Dillmann R, Meinzer HP, Müller-Stich BP (2015) OpenHELP (Heidelberg laparoscopy phantom): development of an open-source surgical evaluation and training tool. Surg Endosc 29(11):3338–3347CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Kotsis SV (2013) KC Chung: Application of see one, do one, teach one concept in surgical training. Plastic Reconstr Surg 131(5):1194–1201CrossRefGoogle Scholar
  11. 11.
    Lee CH, Oomen PJA, Rabbah JP, Yoganathan A, Gorman RC, Gorman JH, Amini R, Sacks MS (2013) A high-fidelity and micro-anatomically accurate 3D finite element model for simulations of functional mitral valve. In: Ourselin S, Rueckert D, Smith N (eds) Functional imaging and modeling of the heart. FIMH 2013. Lecture Notes in Computer Science, vol 7945. Springer, Berlin, HeidelbergGoogle Scholar
  12. 12.
    Mathur A, Ma Z, Loskill P, Jeeawoody S, Healy K (2015) In vitro cardiac tissue models: current status and future prospects. Adv Drug Deliv Rev 96:203–13CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Ramphal PS, Coore DN, Craven MP, Forbes NF, Newman SM, Coye AA, Little SG, Silvera BC (2005) A high fidelity tissue-based cardiac surgical simulator. Eur J Cardiothorac Surg 27(5):910–916CrossRefPubMedGoogle Scholar
  14. 14.
    Scanlan AB, Nguyen A, Ilina A, Lasso A, Cripe L, Jegatheeswaran A, Silvestro E, McGowan FX, Mascio CE, Fuller S, Spray TL, Cohen MS, Fichtinger G, Jolley MA (2017) Comparison of 3D echocardiogram-derived 3D printed valve models to molded models for simulated repair of pediatric atrioventricular valves. Pediatr Cardiol 39:1–10Google Scholar
  15. 15.
    Stephens SE, Liachenko S, Ingels NB, Wenk JF, Jensen MO (2017) High resolution imaging of the mitral valve in the natural state with 7 Tesla MRI. PLoS ONE 12(8):1–18CrossRefGoogle Scholar
  16. 16.
    Van Praet KM, Stamm C, Sündermann SH, Meyer A, Unbehaun A, Montagner M, Shafti TZN, Jacobs S, Falk V, Kempfert J (2018) Minimally invasive surgical mitral valve repair: state of the art review. Interv Cardiol 13(1):14–19PubMedPubMedCentralGoogle Scholar
  17. 17.
    Vukicevic M, Puperi D, Jane GAK, Little S (2017) 3D printed modeling of the mitral valve for catheter-based structural interventions. Ann Biomed Eng 45(2):508–519CrossRefPubMedGoogle Scholar
  18. 18.
    Witschey W, Pouch A, McGarvey J, Ikeuchi K, Contijoch F, Levack M, Yushkevick P, Sehgal C, Jackson B, Gorman R, Gorman J (2014) Three-dimensional ultrasound-derived physical mitral valve modeling. Ann Thorac Surg 98:691CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© CARS 2019

Authors and Affiliations

  1. 1.Faculty of Computer ScienceUniversity of Applied Sciences MannheimMannheimGermany
  2. 2.Department of Cardiac SurgeryUniversity Hospital HeidelbergHeidelbergGermany
  3. 3.Faculty of Computer ScienceMagdeburg UniversityMagdeburgGermany

Personalised recommendations