Marc Gillinov, MD, made a commitment to cardiovascular innovation at a young age. A high school intern at Cleveland Clinic, Dr. Gillinov received his introduction to heart surgery from none other than skilled surgeon, serial innovator, and former Cleveland Clinic President & CEO, Toby Cosgrove, MD. “I watched a mitral valve repair operation and thought, ‘I need to learn how to do that,’” said Dr. Gillinov. He then chuckled at the length of his commitment, clarifying that nearly 20 years would pass before he got the chance.
But Dr. Gillinov would not only learn how to do it and do it well; he would eventually lead the team of individuals doing it every day at an institution whose heart program holds a 26-year streak as No. 1 in the nation. After an education at Yale College and Johns Hopkins University School of Medicine, and a residency at The Johns Hopkins Hospital, Dr. Gillinov joined Cleveland Clinic’s cardiac surgery staff in 1997. At present, he is Chairman of the Department of Thoracic and Cardiovascular Surgery in the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. He also holds the Judith Dion Pyle Chair in Heart Valve Research, chairs the NIH-funded Cardiothoracic Surgical Trials Network, and is Surgical Director of the Center for Atrial Fibrillation at Cleveland Clinic.
Dr. Gillinov is a recognized expert in mitral valve repair surgery, robotic heart surgery, and the study and treatment of patients with atrial fibrillation. Performing more mitral valve surgeries annually than any other surgeon in the world, he champions a substantial portion of Cleveland Clinic’s 4,000+ heart surgeries each year. Dr. Gillinov has been instrumental in the development of new, less invasive treatment options for patients with mitral valve disease and atrial fibrillation. He has been granted patents for several innovations, including a patent disclosing new techniques for valve repair.
Still, Dr. Gillinov is humble in his statements and anxious to bring about further cardiovascular advances for patients in his hometown and abroad. Below are some of Dr. Gillinov’s thoughts as they relate to innovation in the field of cardiac surgery – its presence, importance, and best examples at Cleveland Clinic:
Responses have been lightly edited for clarity and length.
Question: We've sprinkled these interviews throughout the Heart, Vascular & Thoracic Institute – what is your specialty within cardiovascular care, and how would you define it to the layperson?
Marc Gillinov, MD: My specialty within cardiovascular care is heart surgery or cardiac surgery, and my specialty within that is repair of the mitral valve. The mitral valve is one of the four valves in the heart, and the valves in the heart have a single function – to make sure the blood flows in one direction, the right direction. Sometimes people develop what's called mitral valve prolapse, meaning the mitral valve in the heart becomes a little floppy. Some of those with a floppy, prolapsing valve develop a leak, and when the leak is severe, we repair the valve. Repairing the valve is a lot more challenging than replacing it, but you're always going to be better off with the valve that you were born with versus introduction of a new valve from a pig or a cow or a valve that’s mechanical or metallic.
Repairing the valve is one thing. The second thing, though, is to repair it with a small incision – maybe just a couple of inches long through the side, so that you recover more quickly and don’t appear to have had heart surgery at all. This is something we accomplish through use of the surgical robot. Robotic cardiac surgery is a specialty of mine, and a great innovation of the last few years.
Q: Along those lines, how have you seen cardiac surgery evolve over the course of your practice? From when you watched Dr. Cosgrove, to operating with robotic technology today, how do you recall that timeline of innovation?
MG: The innovations in cardiac surgery over the last 20, 25 years have revolved around two factors: one, safety, and two, being less invasive. Safety has improved dramatically. At the beginning of cardiac surgery, survival and good outcomes were almost flip-of-a-coin odds. Cardiac surgery was a big deal. Of course, it's still a big deal, but it is incredibly safe. These days, if you come in for a mitral valve repair operation, the risk of the surgery is less than one in one thousand. That's the kind of operative risk you'd get with an appendectomy or gallbladder operation. Many types of heart surgery now are unbelievably safe.
As I mentioned before, the second innovation is the ability to use special instruments and tools (like the surgical robot) to avoid the standard heart surgery incision (called a median sternotomy) right down the middle of the chest. These days we can do many operations via a small incision and use the robot – which has a fabulous high definition camera and instrumentation that's unlike anything we had years ago – for excellent visualization and mobility.
Q: I would imagine you've had a good hand in decreasing surgical invasiveness through technology development. Are there any past projects you'd like to highlight?
MG: Many of the techniques and technologies that enable us to do mitral valve repairs were developed right here at Cleveland Clinic. Working with our engineers, Innovations staff, and surgeons, we have developed means to repair the valve successfully and safely.
In the last few years, we've also had a big focus on stroke prevention in people with atrial fibrillation who also need heart surgery. A lot of strokes come from an area of the heart called the left atrial appendage (LAA), which is a little outpouching or cul-de-sac in the heart. Here at Cleveland Clinic, we've developed a system to surgically exclude that area of the heart, so blood clots can’t form there or break loose and cause strokes.
Known as the AtriClip device, the LAA management system was licensed by Cleveland Clinic to atrial fibrillation solutions company, AtriCure. In peer-reviewed publications, the AtriClip device achieved a successful LAA exclusion rate of 97% on average. Upwards of 200,000 AtriClip devices have been implanted to date. To learn more about the AtriClip technology, click here.
Q: What are you working on now? What are you and your team innovating over there?
We're working on ways to make things as minimally invasive as possible and extend minimally invasive and robotic platforms to more patients. In the beginning, less invasive and robotic-integrated approaches were only appropriate for a very small subset of patients. Now, we are extending the pool.
We’re also exploring aortic disease and ways to fix the valve and the aorta – the largest artery in the body. It is now often possible to repair aneurysms of the aorta without even doing surgery. So again, our work focuses on two different but related goals – make things safer, make things smaller. Smaller, meaning less invasive.
Q: I would assume they are related, yes? The less invasive you are, the safer the procedure is likely is to be?
Safety and smaller are not always related. We want to avoid getting caught up in the idea of being less invasive at the expense of safety. Our goal is to merge the two, so you get the safest and the least-invasive methods together in the same procedure.
Q: How has COVID-19 changed your practice? Describe your experience providing care in the year 2020.
In 2020, many patients were afraid to come to the hospital, and they delayed their treatment. People with cardiovascular disease let it fester and get worse and developed heart damage. Toward the end of the year, these patients began to show up, but many of them were in a more advanced disease state – a much more complex situation. We’re just grateful that we’re still able to help these patients.
All in all, though, we never shut down cardiac surgery during COVID-19. We didn't shut it down because it's too vital. We wanted people with heart disease to always have the option, the ability to get treated. And they did. Our services have remained at 100%. We are open for business. We are here to help people – through the pandemic and beyond.
Q: What are your predictions for the future of cardiovascular care?
It would be ideal if we in the cardiovascular field could know who's going to develop a particular condition. Think along the lines of BRCA genes and their implications for breast cancer – enabling increased surveillance and more targeted or focused treatment when the breast cancer eventually occurs. We're not quite there yet. We're not at that level with cardiovascular disease. But I think we will be. For example, we've just started a biobank
at Cleveland Clinic for cardiovascular disease, where we will be collecting blood and tissue that was going to be discarded from all patients having heart surgery (according to protocols and patient permissions). With the largest program in North America – more than 4,000 heart surgery patients a year – we’re going to very quickly have the largest vascular cardiac surgery database, or biobank, in the world.
That's going to enable us to do some amazing research and get some answers. Eventually, I'll be able to look at someone and say, “Here's why you’ve got mitral valve prolapse.” When this person asks me, “What about my kids? Are they going to have it too?" Right now, my answer is, “It's very unlikely.” I'd like to be able to refine that and say, “The answer is no, because your disease was caused by these genes. Those genes were not transmitted to your children.” Right now, we're a little bit fuzzy on that, but we're going to get much more focused and enable specific answers and targeted treatments for truly superior care.