Taking It to Heart

Marc Gillinov’s interest in heart surgery started early, when he got a summer job at Cleveland Clinic at the age of 16, working under Toby Cosgrove, who is now the clinic’s CEO. It was there that Gillinov first witnessed Cosgrove performing heart surgery. “To watch somebody repair a heart that wasn’t working, using a tremendous amount of technology, working with a team of specialists, and give that person the opportunity to have a normal life – I hadn’t seen anything like it before,” Gillinov says. “I immediately thought, ‘I want to learn how to do that.’”

Gillinov is now Surgical Director of the Center for Atrial Fibrillation and the Judith Dion Pyle Chair in heart valve disease at the clinic, specializing in treating atrial fibrillation, the most common form of abnormal heart rhythm. People with atrial fibrillation may sense a fluttering or extra beats or missed beats or a fast and irregular heart beat. About 20-25% of all people develop it at some point in their lives.

“It causes your heart to be less efficient, raising the risk of heart failure,” explains Gillinov. “It can cause symptoms such as shortness of breath and tiredness. When the heart is not contracting regularly, the blood can pool in the heart and form blood clots, and when the clots get into the circulation they can cause strokes.”

About one in five strokes in elderly people is caused by atrial fibrillation; and when someone with atrial fibrillation has a stroke, it tends to be more severe.

The most important treatment for atrial fibrillation is warfarin, a blood thinner, which reduces the risk of stroke, though it is not without its drawbacks, because it can cause bleeding.

Making a choice

There are three other treatment pathways: medical treatment, catheter ablation and surgical ablation. “Medical treatment involves making a choice: do we want to try to get the person back into normal rhythm with drugs? Or do we want the person to stay in atrial fibrillation, keep the heart rate down and give blood thinners? That would be called a strategy of rate control, keeping the heart rate down, versus rhythm control, trying to get the person to normal heart rhythm.

“That’s the first thing you do with medical therapy: choose one of those two and do it. If that fails, then you can consider a catheter ablation, where an electrophysiologist places catheters into the heart to destroy the abnormal cells causing the atrial fibrillation.

“If that doesn’t work, or if the person has another reason to have heart surgery – for example, a lot of people who have this heart rhythm also have mitral valve problems – we can do a heart surgery approach using a maze procedure. The maze procedure creates scar tissue in the heart to block the abnormal conduction. This works about 80-95% of the time.”

Gillinov believes when people are diagnosed with atrial fibrillation, they should follow this pathway of first having medical therapy, then catheter ablation, then surgery if catheter ablation fails or if there is another reason for surgery, such as a mitral valve problem.

“Because there are different therapies, you can’t have one doctor who says, ‘I am an atrial fibrillation doctor. I treat everyone with atrial fibrillation,’” Gillinov points out. “That’s why we have a team, because some people work on medical therapies, some people work on catheter therapies, some people work on surgical therapies. And together you figure out with the patient what fits them.

“We also carry out extensive research to develop new therapies. The state of Ohio has provided more than $20 million of funding for Cleveland Clinic, Case Western Reserve University and the University of Cincinnati to work together and with industry to develop new therapies, and we’re the lead center on that.

“One of the things we’re working on is a way to try to prevent strokes associated with atrial fibrillation. We have developed a special clip that clips off part of the heart where the blood clots form. This clip is in clinical trials now in Switzerland, and is looking good so far.”

Repairing valves

On the mitral valve side, the most common condition Gillinov treats is mitral valve prolapse, in which the valve becomes floppy and leaks. About three percent of all people have it. For those who do, Gillinov recommends having an echocardiogram every few years, and taking antibiotics before dental treatment. “The recommendation to take antibiotics is controversial,” he says. “If you ask is it cost effective, the answer is no, it’s not. But if you’re not allergic to antibiotics, I would say take them, because if you get an infection of a heart valve, that’s a disaster.

Gillinov repairs valves that have prolapsed and are leaking, using tiny incisions, or ports, frequently with a surgical robot. The refinement of this technique is relatively new, and Gillinov and his team have been talking with design firms to come up with ways to repair valves in an automated fashion.

Which leads to something of a contradiction, as he explains, “Today, if I repair a valve, I use a lot of very advanced technology to cut and sew tissue. That’s using 21st century technology with 19th century technique: I’m still cutting and sewing just like they did over 100 years ago. One of the things we’re developing is a platform and series of techniques so that we can treat the valves more expeditiously and better.

“Along those lines, we have developed percutaneous, or catheter-based, ways to treat the valves. I’ve been involved with a group that has developed a percutaneous way to make some valves stop leaking. That’s a percutaneous annuloplasty – annuloplasty is a ring we put around the valve to bring the leaflets together. It’s like putting a new doorframe around a door, a smaller doorframe, to push the leaflets of the valve together.

“We hypothesized eight years ago that we could do this without surgery. And, in fact, we have proven we can. Now we’re doing a clinical trial in Europe, primarily in Germany, to determine which are the best patients for this technology. The idea is to repair more valves and to do it less invasively and even nonsurgically.”

Gillinov appreciates the irony of this – he’s a surgeon and he’s involved in developing nonsurgical methods of operating. “My approach is that surgery is going to get less and less invasive, maybe to the point of not being surgery any more. I can either sit back and watch this happen, or be one of the people that works to try to make it happen in a more efficient and safer way. And I chose the latter.

“That’s following Toby Cosgrove’s lead. When I was 16, he said to me, ‘If you see something that is difficult, figure out a way to make it easy. If you see something that is impossible, figure out a way to make it possible.’ His idea for innovation is the one I’ve adopted, which is to figure out where the unmet needs are – what is hard to do and what can’t we do – and take it as a challenge: make it easier, make it possible.”