Dramatic advances made in cardiac care
In August 2024, Debbie Hillwig was facing her second heart surgery in seven years. The first surgery to replace her aortic valve required open-heart surgery. Now 71, another surgery carried considerable risk.
“My two choices were having the mitral valve replaced or just continuing medically treating myself and living as long as I could, as well as I could,” said Hillwig, a retired nurse who lives in Butler.
Instead, she participated in a clinical trial that replaced her mitral valve with an experimental valve that has yet to be approved by the Food and Drug Administration. The Tendyne valve was placed with a catheter, a thin, flexible tube inserted through a small incision. It allowed the surgeons to avoid cutting through the scar tissue from Hillwig’s first surgery.
“It dramatically changed the valve leakage and valve stenosis that she was suffering from. And it essentially gave her a brand new valve,” said Dr. Walter McGregor, the cardiac surgeon at Allegheny Health Network who performed the surgery. “The stay in the hospital was certainly shorter. Her recovery was much shorter, and patient performance is the best testimony.”
Six months after the procedure, Hillwig says she feels stronger and more energetic. “I think I’m doing quite well,” she said.
Dramatic and rapid advances in cardiovascular surgery and interventional care over the last 20 years are extending life and shortening recovery times for patients such as Hillwig. From minimally invasive procedures to robotic surgery and artificial intelligence assistance, these improvements are saving lives every day.
“I’d say the biggest advance that we’ve had in heart surgery is that over the past 20 years, heart surgery has become extremely safe,” said Dr. Ibrahim Sultan, chief of cardiac surgery at UPMC and core director of its Heart and Vascular Institute. “The average risk of death from heart surgery is less than 1% now in the United States.”
Perhaps the biggest advance in heart surgery is the option to avoid open-heart surgery. During open-heart surgery, surgeons make a large incision in the chest, split the breastbone, stop the heart and use a heart-lung machine to keep the patient alive during surgery. In its early days, open-heart surgery had a high mortality rate, and patients typically spent eight to 10 days recovering in the hospital followed by weeks of recovery at home.
In the 1990s cardiologists began using catheters and stents to unblock coronary arteries, allowing patients to avoid open-heart surgery. With advances made over the last 20 years, the use of catheters to repair or replace aortic and mitral valves are now commonplace. These surgeries require only a small incision, as was the case in Hillwig’s surgery to replace her mitral valve. Moreover, her heart didn’t have to be stopped during the operation.
“It’s absolutely amazing to see where it’s come from where we can literally do a little puncture with no real surgical incision and take a valve and be able to replace the existing valve with a minimally invasive approach,” said Dr. Richard Begg, medical director of the Cardiovascular Service Line for Independence Health System. “And this often means a one-night stay in the hospital.”
Today surgeons can close holes in the heart with devices delivered by catheters, procedures that once required major surgery. Even bypass surgery — the most common heart operation, where surgeons must bypass an obstructed artery — in some cases can be done without open-heart surgery.
Minimally invasive surgeries also expand options for elderly patients, who even 10 years ago would not have been considered candidates for open-heart surgery.
Robot-assisted surgery also is becoming common for heart surgeons, McGregor said. Robots used in surgery are an extension of the surgeon. They allow a surgeon to be inside the patient’s body with a magnification and depth perception far beyond the ability of the human eye.
Robots were first used to help surgeons remove organs such as gall bladders and appendixes or remove sections of the colon or lungs. Today, heart surgeons use robots to repair and reconstruct heart valves or to replace them entirely through small incisions in the groin.
“It’s almost a telepresence mode, meaning you’re in one location but you seem to be in a different location,” McGregor said.
Artificial intelligence (AI) is another game changer for heart surgeons. AI platforms can summarize a conversation between a surgeon and a patient and even suggest options that perhaps weren’t considered by the doctor, McGregor said.
At UPMC, AI helps patients understand the risks of surgery. Sultan said AI crunches data from thousands of heart surgeries within the UPMC system and generates a number that tells the patient their risk of complications. If a patient’s risk of stroke is high, for example, the surgeon can take precautions to reduce the risk and be better prepared to respond if a stroke does occur.
Three-dimensional imaging created from a CT scan can provide surgeons an image of a patient’s heart before surgery. They can spin the image in any direction and look at it from any angle, helping a surgeon choose the precise size of a heart valve implant and visualize how it will sit in the patient’s heart. They can determine if it will impact other portions of the heart. Surgeons can also leverage 3D printing if they want to hold the model in their hand.
Advances in cardiology care are not limited to surgery. Begg highlighted amazing advances in interventional cardiology, a specialty that diagnoses and treats heart and blood vessel conditions with catheters. Early in his 35-year career, cardiologists would put a heart attack patient in a dark room, give them medicine and hope for the best.
“Where we are today is very aggressively getting in and being able to open blocked arteries with balloons and stents and basically save lives by doing that,” he said.
Interventional cardiologists today have an array of advanced tools and devices with which to treat patients, including intra-aortic balloon pumps to help the heart pump more blood and Impella devices that allow the heart to rest and heal during a procedure. If the heart is not functioning at all, they can use ECMO, an external bypass procedure that supports the heart as cardiologists work.
“It’s a pretty impressive procedure and pretty impressive equipment,” Begg said, “but it’s also very successful in saving lives. So that’s kind of a big deal.”
Interventional cardiologists can close holes in the heart with catheter-inserted devices. They can implant a WATCHMAN device in the heart to prevent a stroke in patients with atrial fibrillation. They can use a catheter-deployed Inari device to vacuum blood clots from the lungs. Cardiologists today use cardiac ablations to treat irregular heartbeats, including a new technology called pulsed-field ablation. This ablation uses short electrical pulses to selectively target the heart’s muscle layer responsible for erratic electrical signals.
Today’s tools include wireless pacemakers and ICDs, small electronic devices that monitor the heartbeat and administer an internal shock when the heart goes out of rhythm. Patients experiencing heart failure can benefit from optimizers, which are implantable devices that send electrical pulses to the heart muscle to increase the strength of the heart’s contractions. Cardiologists can even insert chips under the skin to record a patient’s every heartbeat.
“These are very, very exciting things that are going on across the spectrum,” Begg said.
While the United States leads the world in heart surgery and intervention advances, it fails in another important category: prevention. Heart disease is the leading cause of death in the United States. Risk factors include high blood pressure, high cholesterol, smoking and obesity. Studies have shown that nearly 80% of cardiovascular diseases can be prevented with lifestyle changes such as exercise, a healthy diet and regular checkups.
“If we can lose weight and we can walk and we can be active, it’s going to help offset all of those other risk factors,” Begg said.
UPMC’s Sultan agrees. Follow a nutritious diet, stay active and be aware of your family history. If you do need cardiac care, educate yourself.
“Do your research. Look up the hospitals you’re considering. Look up the surgeons you’re thinking about and ask them intelligent questions,” he said. “What are your volumes like? What are your outcomes like? What kind of team do you have? How many of these have you done?”
Technology and procedures for cardiac surgery and care will continue to advance through clinical trials and research. Hillwig is proud that her experience with the experimental Tendyne valve might someday help others.
“I thought, if it helps me, terrific. I certainly want it to help me. But at the same time if it helps somebody else down the road and this is a procedure that is done for people that need mitral valves, it’s worth it.”
This article first appeared in the April edition of Butler County Business Matters.
