Now in a Phase II trial comparing it with open-heart surgery, the MitraClip was brand new in April 2005, when Peter Block, an interventional cardiologist at Emory Healthcare in Atlanta, snaked it up Lord’s femoral vein. Block steered a catheter into her right atrium, through the septum to the left atrium and down to the valve. Inside that catheter was another bearing the MitraClip, which is made of nitinol, a metal that can be bent and will automatically reassume its shape when released.

“The trick is lining up and delivering the catheter so the clip comes at the right angle to all three planes of the valve,” Block says. He opened the clip, advanced it through the valve and retracted it to capture both leaflets, then checked a color Doppler echocardiogram to see how much regurgitation remained. Though Lord had some residual regurgitation, her health improved markedly. “I’m as good as ever,” she says.

The MitraClip is one of several devices being tested as low-risk (though technically challenging) percutaneous fixes for mitral valve prolapse and other mitral valve problems. While Oz doesn’t expect percutaneous devices to have the effectiveness of surgical measures for every type of mitral valve disease, he does think they could each year benefit as many as 10,000 patients who do not want to accept the risks associated with open surgery or are in the early stages of the disease.

Percutaneous repairs for deteriorated aortic valves, though still a few years away, could ultimately provide similar benefits to a different, sicker group of patients. Aortic valve disease accounts for more than half of the approximately 100,000 patients who have valve surgery each year, and it’s a debilitating condition. “With symptomatic aortic stenosis, patients go steeply downhill,” says Igor Palacios, an interventional cardiologist at the MGH. “They have a 50% mortality rate in the first year, but surgery brings their life expectancy back to normal.” Very sick patients, however, can’t risk surgery, and while no percutaneous aortic valve device has yet been approved by the U.S. Food and Drug Administration, that could change soon.

Several devices—made by CoreValve, Edwards LifeSciences, Direct Flow Medical, Sadra Medical, Heart Technologies and AorTx—are in early trials. “And on the horizon are a host of extraordinarily clever aortic valve devices that are smaller, more user-friendly and easier to deploy,” says Emory’s Block. “They will also produce better long-term results.”

If the new aortic valve devices prove as safe and effective as Block and others expect, they could drive another mainstay of cardiac surgery out of the operating room and into the cath labs. Retired surgeon James L. Cox, of Cox-Maze fame, doesn’t deny that the landscape is changing. “If you looked only at what has served as the basis of our profession, cardiac bypass surgery, there would be reason to worry,” Cox says. “And if our future depended on the development of more surgery for valve disease, we’d be in trouble.”

But Cox says doom and gloom about the future of heart surgery is nothing new. “They were predicting our demise before we even started,” Cox says. “I was an intern at Duke looking down the barrel of 10 more years of training when my mentor told us we’d have nothing left to do. I thought, ‘Holy cow! I might as well try to be a baseball player.’ But it has always turned out that just when you get to where it seems you might not have anything new to do, something pops up.”

That “something” might be what the MGH’s Palacios calls percutaneous valve surgery. He and other cardiologists believe that the trend toward less invasive cardiac procedures is creating new opportunities for surgeons and interventional cardiologists to work together to benefit different patient populations, such as those who have severe vascular disease that prevents the threading of a catheter from the groin to the heart. In one new technique a surgeon makes a small incision through the chest wall to reach the apex of the heart, and an interventional cardiologist inserts a very short catheter through the apex to the left ventricle to deploy an artificial aortic valve. Palacios dreams of the day when such collaborations become commonplace.

And even surgeons working on their own may find plenty to do, says Cox, who predicts that developing less invasive surgical procedures for atrial fibrillation and new devices to treat the nearly 5 million people with heart failure could ultimately triple the number of cardiac operations. Meanwhile, factors such as the obesity epidemic and the surge of baby boomers reaching the age of diabetes and cardiovascular disease could keep old-fashioned cardiac surgery in demand.

“If the current workforce of heart surgeons drops and if the number of cases suddenly increases, we will have a crisis,” says Cox. “Not the crisis of surgeons not having anything to do, but of not having enough surgeons to do what needs to be done.”

  Dossier

1. “Percutaneous Heart Valve Replacement: Enthusiasm Tempered,” by R. David Fish, Circulation, October 2004. An insightful overview of the challenges facing surgeons and cardiologists in addressing the unmet need for less invasive means of treating valvular disease.

2. “Surgical Management of Atrial Fibrillation,” by James L. Cox, Medscape Cardiology, Vol. 9, No. 1, 2005. A concise overview of atrial fibrillation and the development of the surgical Cox-Maze, “mini-maze” and pulmonary vein isolation procedures for treating AF.

3. “Controversies in Cardiovascular Medicine: Should atrial fibrillation ablation be considered first-line therapy for some patients?” pro position by Atul Verma and Andrea Natale; con position by Benzy J. Padanilam and Eric N. Prystowsky, Circulation, Vol. 112, No. 8, 2005. An in-depth debate about the merits of catheter ablation to treat atrial fibrillation, compared with drug therapy alone.