The Future of Heart Valve Surgery with Dr. Michael Acker
Written By: Adam Pick, Patient Advocate, Author & Website Founder
Medical Expert: Michael Acker, MD, Chief of Cardiovascular Surgery at Penn Medicine Heart & Vascular Institute
Published: March 17, 2021
During the past 25 years, the treatment of heart valve disease has radically transformed. New techniques, imaging capabilities and medical devices have greatly enhanced the patient experience with minimally-invasive procedures, shorter hospital stays, faster recovery and less pain.
But… What will the future of heart valve therapy look like? Can it continue to advance? Or, has valve therapy reached an innovation plateau?
To answer these questions, I interviewed Dr. Michael Acker, the Chief of Cardiovascular Surgery at Penn Medicine Heart & Vascular Institute. During his 30-year career, Dr. Acker has performed 9,000+ cardiac procedures and 3,000+ heart valve operations. Dr. Acker has also been intimately involved with the research and development of many medical devices including TAVR.
Key Learnings from Dr. Acker
In this video interview, Dr. Acker touches on several great points about the evolution and the future of heart valve therapy – both repair and replacement. Here are the highlights I wrote down from our discussion:
- Dr. Acker sees the improvement in valve therapy as an evolutionary process. There are typically no “light switch” innovations in medicine. Instead, physicians and medical companies typically build upon on previous successes, steps and failures.
- The utility of mitral valve repair techniques have experienced a renaissance during the past 30 years. Today, reproducible techniques have evolved to help patients benefit from mitral valve repair procedures. The benefits of mitral valve repair operations include enhanced durability, freedom from re-operation, no anticoagulation therapy, and a normal life expectancy.
- The utility of smaller-and-smaller incisions to access a defective heart valve is an ongoing and important phenomena within heart valve surgery. Access points have decreased from a sternotomy to minimally-invasive ports to robot-assisted techniques. When appropriate, the size of an incision for a procedure can shift from inches to centimeters.
- Transcatheter aortic valve replacement (TAVR) provides an interesting blueprint for how new technologies may impact patients with heart valve disease (e.g. aortic stenosis). While TAVR was initially limited to the highest risk patients, TAVR is now helping low-risk patients. At Penn Medicine, 80% of all aortic valve replacements are done using TAVR.
- With the success of TAVR, a current focus among physicians, researchers and industry is using catheter-based approaches to treat the mitral valve.
- While there is more complexity specific to using catheters to treat the mitral valve, Penn Medicine is currently evaluating transcatheter mitral valve repair (TMVr) devices including the MitraClip and transcatheter mitral valve replacement (TMVR) devices.
- In the next five years, Dr. Acker believes that TMVR is going to “take-off” as physicians may be able to replace mitral valves without opening the heart, without cardiopulmonary bypass and without using sutures.
- An underlying innovation resulting from medical advances within heart valve treatment is that newer techniques and technologies enable physicians to treat new patient populations that previously had no therapies available to them.
Thanks Dr. Acker & Penn Medicine!
Many thanks to Dr. Acker for taking time away from his very busy practice to share these fantastic insights with our patient community. In addition, I’d like to thank Penn Medicine for taking care of so many patients in our community including Patricia Garcia, Michael Casey, and Theresa Gusset who Dr. Acker successfully operated on.
- See Dr. Acker’s Interactive Surgeon Profile
- Explore the Penn Medicine Heart Valve Microsite
- Clinical Trial Alert: REPAIR MR Now Enrolling Mitral Valve Patients
Keep on tickin!
Adam Pick: Hi, everybody. It’s Adam with heartvalvesurgery.com, and this is a special surgeon question and answer session all about the future of hear valve therapy. I am thrilled to be joined by Dr. Michael Acker who is the Chief of the Division of Cardiovascular Surgery at Penn Medicine in Philadelphia, Pennsylvania. During his incredible career, Dr. Acker has performed over 9000 cardiac procedures, of which 3000 have involved either a valve repair or valve replacement. Needless to say, I’m excited to bring him onto the call. Dr. Acker, are you there?
Dr. Acker: Yes. Hi, Adam.
Adam: Hi, Dr. Acker. Thanks for joining us today. We’re going to get to our topic about the future of heart valve surgery, but I’ve got a couple questions just about you and your practice there. Got to start with this one. When and why did you decide to become a cardiac surgeon?
Dr. Acker: That’s a great question. I guess I always was – knew I wanted to be a doctor. Frankly, there was nothing cooler than being a surgeon, and then if you look at all the different types of surgery, heart surgery is so cool. Stopping the heart, starting it, fixing it, opening it up. The technology was really cutting edge and exciting, and also it’s very dramatic and romantic being a heart surgeon, so as I went through my training as a surgeon, there was nothing that could compare to the romanticism and the excitement of heart surgery.
Adam: Dr. Acker, I love hearing about your passion for cardiac surgery. Let’s talk about valves, which are a very big part of your practice. What attracted you to heart valve surgery?
Dr. Acker: When I started heart surgery in the mid-‘90s, 90% of what was heart surgery was coronary bypass surgery, and it was a untapped field if you will. The second thing that really influenced me was an early association with Alain Carpentier, who’s probably the founder of valve heart surgery if you will, both the development of useful clinical prosthetic – bioprosthetic valves as well as the guy who really developed reproduceable techniques on how to repair the mitral valve so you didn’t have to replace it.
Adam: Dr. Acker, I did not know about your connection to Dr. Alain Carpentier. That is fantastic, and I’ve got to ask you. Given your tremendous history and knowledge of heart valve surgery, would you say it has evolved or radically transformed during your career?
Dr. Acker: I think it’s both. Like most things, you just don’t flip a switch in medicine, right? What you do, you evolve. You build on previous evolution and previous steps as you stand on the shoulders of the people that went before you.
Adam: Dr. Acker, can you maybe give us an example of this simultaneous evolution and radical transformation?
Dr. Acker: Certainly, the mitral valve is a nice example, right? When I was training, very few mitral valve repairs were done. We replaced valves by cutting out as much tissue as possible and putting in the biggest valve possible. That’s not done anymore. Now we do just the opposite. The whole structure of the mitral valve is intimately related to the left ventricle, and we try to maintain that. We also developed Carpentier’s techniques to such a great degree, they’re very reproduceable. I teach them to my residents now, and they leave our residency training really expert at mitral valve repair.
Adam: Dr. Acker, I’m really curious to know. Is it possible that these evolutions and reproduceable techniques are enabling you to treat patients who maybe you previously wouldn’t treat?
Dr. Acker: We operate on people that have much sicker hearts with mitral valve regurgitation than we ever would have attempted. They would have all died, and now we can get people with sick hearts through and make them better. As all this was happening, we were also evolving our approach to the mitral valve. Can we do it through smaller incisions? Can we do it through using laparoscopic instruments? Can we do it with the assistance of the robot, which also evolved over the last 20 years? Can we do it with new technologies such as a HeartcoR Endoballoon, which came about, actually, in the late ‘90s and developed from there. Yeah, we can.
While that was all developing, the aortic valve space was also developing, right, and it was developing with a catheter-based approached, so-called TAVR procedure. Penn, under the leadership of my partner Joe Bavaria, was one of the first in the country to do the catheter-based aortic valve replacement, the TAVR, which we did in 2007.
Adam: Specific to patient risk, Dr. Acker, how has TAVR evolved?
Dr. Acker: We went from doing only the highest, highest-risk patients that couldn’t tolerate surgery to high-risk, intermediate-risk, now to low-risk. It still leaves us, I would say, about 20% of aortic valve replacements are done open surgically, but the vast majority, 80%, not only are they done with the catheter-based technique, they’re done with being awake. They don’t go to sleep, and they can leave the hospital in two days or so. Yeah, that’s a tremendous evolution.
Adam: I’ve got to ask. Did all the success around TAVR spark a wave of transcatheter interest for the mitral valve?
Dr. Acker: All this venture capital technology. We can do it with the aortic valve, can’t we do the same thing with the mitral valve or the mitral repair techniques and technologies? They developed about 10 to 15 years ago the first one, the mitral clip by Abbott. It’s basically a clothespin that pinches the anterior and posterior leaflets together. Can that be a way to help some people? It was not the great result that we saw with TAVR, but an incremental result.
We can get severe down to moderate, some cases less, but what we found is it was more effective in a different space, the so-called functional or secondary leak space, secondary to a heart attack. As the mitral clip developed, other companies jumped in. Artificial cords and annular rings, and all these that could be placed without open-heart surgery. Again, no grand slams, but little – but learning, right?
Adam: Is there any one specific innovation that you’re most excited about right now?
Dr. Acker: I’m very, very interested in the TMVR technology, the replacement of valves without open-heart surgery, without putting sutures in, and I think that’s really going to take off in the next five years.
Adam: I’ve heard because of the complexity of the mitral valve, it’s not as simple as TAVR. I’m not saying that TAVR has been easy, getting to where we are with that, is there some truth to that? It’s a little more complex TMVR than TAVR?
Dr. Acker: I think it is, Adam. I think the mitral valve for one is intimately associated with the left ventricle itself. It also is very, very close to the aortic valve. It also is rarely involved with that heavy calcium where TAVR relies on that calcium to sit and not move. New technologies that anchor – new anchoring technologies had to be developed. It is more complex.
Also, the mitral valve insufficiency is somewhat more complex than just aortic stenosis, so proving effectiveness is more difficult than in aortic stenosis. Aortic stenosis kills you quickly. Mitral valve leak probably doesn’t, so the trials that need to be developed are much – are going to need to be longer term than aortic valve. Everything is going to be more complex.
Adam: Dr. Acker, big question I have for you is what’s next for heart valve therapy?
Dr. Acker: I see it slowly evolving over the next decade to the point where I think many patients will be able to be addressed transcatheter, smaller incisions, robotically. Sick patients will still perhaps need a surgical open-heart repair, yet we know how to get those hearts through, so there’s been a lot of innovation, a lot of evolution, all to the really benefit to our patients.
Adam: Dr. Acker, I love that you brought it back to the patients. There’s no doubt that these evolutions and innovations and technologies have been helping you treat patients from heartvalvesurgery.com like Patricia Garcia, Michael Casey, and Theresa Gusset. What I want to do now is I want to thank you on the behalf of all the patients out there for your leadership there at Penn Medicine, for all the great research you and your team have been doing to further this space, and again, taking time away from your very busy practice to share your clinical insights and your experiences with our community. I can’t thank you enough. Thanks for being with us again today. As we say here, keep on ticking.
Dr. Acker: Thanks, Adam. It’s been really a lot of fun talking to you today.
Adam: Alright. Take care, Dr. Acker.
Dr. Acker: Bye-bye.