A small country in the Middle East is now home to some of the most advanced cardiovascular procedures in the world.
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The nation is the United Arab Emirates (UAE), and it’s making a name for itself in heart care throughout the region and beyond following the 2015 opening of Cleveland Clinic Abu Dhabi, a multispecialty hospital in the capital city of Abu Dhabi designed as an extension of Cleveland Clinic’s model of care.
“Abu Dhabi has a vision for innovation, research and education,” says interventional cardiologist E. Murat Tuzcu, MD, who relocated from Cleveland Clinic’s main campus in Ohio to serve as Chief of Cardiovascular Medicine and Chief Academic Officer at Cleveland Clinic Abu Dhabi.
“Our commitment to research and education, as well as to clinical excellence, is why leaders of Abu Dhabi are collaborating with us,” he adds. “They want to be a center of excellence in health care and create an innovation platform in the medical field. While they’re investing energy and resources in education and innovation, Emiratization [i.e., an initiative of the UAE government to increase its citizens’ participation in the UAE workforce] is always a top priority. We at Cleveland Clinic Abu Dhabi are committed to training the future Emirati healthcare providers, educators and researchers.”
“New approaches to medicine are very welcome in this country,” adds Johannes Bonatti, MD, Chief of Cleveland Clinic Abu Dhabi’s Heart & Vascular Institute. “There’s big interest in innovation.”
That culture is a natural fit with Cleveland Clinic, which operates the high-tech facility in partnership with Abu Dhabi’s Mubadala Development Company with a specific mission of addressing complex and critical care needs in the Middle East.
Where minimally invasive procedures reign
The facility’s Heart & Vascular Institute has attracted a world-renowned staff from the U.S. and Europe, including five interventional cardiologists and five cardiothoracic surgeons with deep expertise across the spectrum of minimally invasive heart procedures, including some not yet available in the U.S. outside of research settings. That’s thanks to Abu Dhabi health laws that accept both FDA-approved and CE-marked products and techniques.
Patients come to the hospital from all over the world for a range of cutting-edge procedures. Robotic endoscopic heart surgery — including mitral valve repair, CABG and hybrid coronary interventions — and percutaneous repair of atrial septal defects and patent foramen ovale are among the leading examples.
Patients also come for advanced transcatheter interventions. “Teamwork is our fundamental principle,” says Dr. Bonatti. “Many of these procedures are done by interventional cardiologists and surgeons working together in our hybrid operating room. This is new to the UAE and can really make a difference in patient safety and outcome.”
The Middle East is an ideal setting for performing minimally invasive procedures, for at least two reasons:
- The prevalence of diabetes, which raises the risk of postoperative infection and recurrent lesions in bypass grafts and stents (which can be overcome more easily with minimally invasive techniques)
- The region’s traditional cultural emphasis on preserving body integrity, which makes minimally invasive procedures especially preferable to open-chest surgery for some patients in the region
Such cultural preference serves to only bolster the general appeal that minimally invasive surgery tends to have. “Patients don’t want to have their breastbone split and take weeks of their lives for recovery,” says Rakesh Suri, MD, DPhil, Chief of Thoracic and Cardiovascular Surgery at Cleveland Clinic Abu Dhabi, where he also serves as Chief of Staff.
Introducing ‘keyhole surgery’ to the region
The multispecialty hospital is the first in the region to perform CABG without opening the chest, via a “keyhole surgery” technique. When one or two bypass grafts are needed, totally endoscopic coronary artery bypass surgery (TECAB), performed robotically using one or both internal mammary arteries (IMAs), accelerates recovery. TECAB is particularly valuable in patients with diabetes.
“Using both IMAs yields a survival advantage,” Dr. Bonatti explains, “yet some surgeons are reluctant to do this in diabetics, due to the risk of wound infection. TECAB avoids this.”
Theoretically, TECAB can be used to perform as many bypasses as desired. However, in patients with multivessel disease, the procedure is combined with percutaneous transluminal coronary angioplasty (PTCA). Arterial grafts are placed robotically to the most important vessels, and the remaining vessels are stented percutaneously. “Stents are better and longer-lasting than the vein grafts we would put in during surgery,” notes Dr. Bonatti.
Ideally, the procedures are performed simultaneously in the hybrid OR. In cases of renal failure or extended anesthesia time, they may be done in a staged fashion.
Advanced mitral valve repair
Cleveland Clinic Abu Dhabi is likewise the first center in the region to perform robotically assisted mitral valve (MV) repair.
Last fall, Dr. Suri published a study showing that robotically assisted MV repair can be 100 percent effective in treating degenerative MV regurgitation when performed at a center of excellence. “We now have a minimally invasive robotic alternative to open surgery whose quality, safety and durability have been established with unprecedented certainty,” he says.
For patients at unacceptable risk for any type of surgery, Cleveland Clinic Abu Dhabi offers transcatheter MV repair with MitraClip®.
New approaches to TAVR and PTCA
The multispecialty hospital also is first in the region to perform transcatheter aortic valve replacement (TAVR) with guidance by intracardiac echocardiography and without deep sedation. “With light sedation, we can awaken the patient immediately after the procedure and typically are able to discharge them in a day or two,” says Thomas Bartel, MD, PhD, Head of Interventional Cardiology at Cleveland Clinic Abu Dhabi.
He adds that monitoring with intracardiac echo allows for advanced and early detection of potential complications before a patient might deterioriate. “Not every event can be detected by fluoroscopy alone,” Dr. Bartel explains. “Using echo allows us to watch for bleeding and check valve function without using contrast.”
Meanwhile, Cleveland Clinic Abu Dhabi clinicians are free to offer patients bioresorbable vascular scaffolds, which have been widely used in Europe for several years even though the first such device was only recently recommended for approval by an FDA advisory committee (as detailed here). The stent disappears in two to three years, ideally leaving a healthy vessel behind.
For in-stent restenosis — a particular problem in diabetics — Cleveland Clinic Abu Dhabi interventionalists use a cutting balloon to address excess tissue in the lumen, followed by angioplasty with a drug-eluting balloon to inhibit tissue growth. The treatment is pending FDA approval and is new to the Middle East, but has been used in Europe for years.
In the near future, the cardiac innovators plan to combine keyhole surgery with other interventional procedures, including percutaneous aortic valve repair, TAVR and MitraClip placement.
They also will start performing minimally invasive left atrial appendage closure and alcohol septal ablation for obstructive cardiomyopathy — procedures that Drs. Tuzcu and Bartel performed regularly in the U.S. and in Germany and Austria before they joined the 3,200+ caregivers from over 70 countries recruited to Cleveland Clinic Abu Dhabi.
One thing is sure: The division between cardiology and cardiac surgery is becoming increasingly blurred, a development that Cleveland Clinic Abu Dhabi is helping introduce to the Middle East. “As surgery becomes less invasive and interventions become more invasive, we are meeting in the middle,” says Dr. Bonatti.