Fertile Ground for Cardiovascular Research
A Q&A with Robert E. Michler, M.D.
Dr. Michler is the Samuel I. Belkin Endowed Chair; surgeon-in-chief, chairman and professor of surgery and cardiothoracic and vascular surgery; and co-director of the Montefiore Einstein Center for Heart and Vascular Care. He is an internationally renowned cardiothoracic surgeon and researcher, with expertise in multiple specialties, including complex cardiac surgery, heart transplantation, valve repair surgery, ventricular reconstruction for congestive heart failure and minimally invasive cardiac surgery. Dr. Michler was one of the first to perform minimally invasive and robotic surgery in heart patients. His pivotal work in robotics led to approval by the Food and Drug Administration of this advanced technology for mitral valve repair and coronary artery bypass surgery. He is a National Institutes of Health investigator with more than 10 years of NIH funding and joined the faculty of Einstein and Montefiore in 2005.
Heart disease doesn’t seem to elicit the same fear as cancer. Why? Probably because we have a better understanding of heart disease and how to treat it compared to cancer. People feel that cancer is a death sentence despite the fact that more men and women die each year of heart disease than all types of cancer combined. Cancer is often a lingering illness whereas heart disease is often considered curable. But while coronary artery disease, the most common form of heart disease, can be extremely well treated with bypass surgery or by inserting stents, it is a chronic illness that can recur.
Could more be done to prevent heart disease?
That’s the Holy Grail, of course. We have a responsibility to encourage people, especially those at higher risk, to avoid behaviors that might lead to or accelerate heart disease. The challenge is keeping those at risk on a steady course of prevention therapies. Many people find it too difficult to change bad habits. We know many of the genetic factors that predispose people to heart disease, but we don’t yet understand the individual epigenetic factors that control the expression of those genes and affect disease outcomes. While we can offer recommendations for large segments of the population, we cannot yet alter a person’s genes or their expression. One day, we hope to offer individual patients specific preventive measures.
What kinds of clinical trials are being conducted in surgery and cardiovascular surgery at Montefiore?
We have about 30 ongoing trials, including studies of stent implantation, bariatric surgery, atrial fibrillation, reflux disease, infection control during pediatric surgery and neuro-protection for patients undergoing valve replacement, to give just a few examples. Our work through my NIH award has led us to make specific recommendations regarding the treatments of ischemic mitral regurgitation, atrial fibrillation and the use of mechanical circulatory assistance for heart failure. This work has resulted in four articles in the New England Journal of Medicine in the last two years.
What about stem cell therapy for heart disease?
We’re conducting a clinical trial looking at whether injections of mesenchymal stem cells—cells that give rise to blood, bone, cartilage and other tissues—can regenerate heart muscle in heart failure patients being sustained by mechanical-assist devices. This is a limited patient population, and the therapy could one day apply to the many patients who have lost segments of heart muscle—due to coronary artery disease, heart attacks or congenital abnormalities—and are at risk for heart failure. To me, this is the most exciting area of clinical investigation in our field.
In recent years, Montefiore has been involved in several large multicenter trials. What attracts federal funding agencies and industry to this institution?
First and foremost, it is our faculty. We are solid investigators with a track record of excellence in the field of cardiovascular disease. Second, our patient community is a particularly fertile ground for clinical research because of its rich diversity. We often see untreated and more advanced disease, which of course is more challenging to treat. What we learn here can be generalized to many other communities, not only around the country but around the world.
How are you promoting closer ties between researchers at Einstein and clinicians at Montefiore?
We have had many successful collaborations over the 10 years I’ve been on the faculty, and my goal is to strengthen and amplify them. We welcome inquiries from basic science investigators and host research meetings to discuss opportunities. Most importantly, both clinicians and scientists need to reach out and build bridges. We’ve been working in many ways to build our research infrastructure. On the clinical side, we recruited a biostatistician and several research nurses to support clinical trials. We created a research open house, where faculty members can share their studies with one another and the broader research community. We also won a coveted NIH T32 grant, which prepares pre- and postdoctoral fellows to conduct cancer research. This T32 grant is being used to train surgeons to conduct research into the microenvironment of tumors.
Are there unique or unusual cardiovascular health issues in the Bronx?
We see more advanced disease here, and this affects all areas, not just cardiovascular disease. People of lower socioeconomic status are less likely to seek medical attention when disease is in its early stages, perhaps out of fear, uncertainty about where to go and whom to see or cost concerns. We must encourage people to seek medical care when they feel unwell and come in for specific screening tests, especially for heart disease and cancer. Often, patients’ first interaction with the healthcare system is the emergency room, when they can no longer tolerate discomfort or pain or they have an acute event. This is undesirable on many levels, beginning with the unnecessary suffering. And the longer they wait to have a disease diagnosed or treated, the lower the likelihood of having a cure or a good outcome.
How do you reach these people?
You have to convince them that the healthcare system—and specifically Montefiore—is a welcoming place for them and their families. Whether you’re a recent immigrant or a Wall Street banker, we’re going to take extraordinary care of you.
There are many choices for heart care around the region. Why go to Montefiore?
The simple answer is that there is no better hospital. We achieve extraordinary results in surgery while also being convenient for people who live in the Bronx and Westchester. But it goes well beyond that. There’s no condition that can’t be treated by our experts here at Montefiore, whether that’s an asthma attack or complex heart failure.
What’s the status of Heart Care International, the charitable organization you and your wife founded?
We are in our 22nd year. We’ve now treated close to 1,500 children and young adults with heart surgery and an additional 500 with medical treatment. It has been a wonderful source of goodwill and humanitarian aid, and a great educational experience. We’ve taken faculty, residents and medical students from Einstein and other institutions to countries in Central and South America. They have opportunities to see and treat unusually complicated cases as well as diseases no longer common here in the United States, such as rheumatic heart disease.
For me personally, Heart Care International is the expression of everything that I stand for as a physician. Heart Care International represents access to healthcare for those with no hope for care, the care is free and our singular mission is educating and training host country medical professionals.
What about developing countries now confronting the “curse” of affluence in the form of chronic diseases, including heart disease?
If we can help these countries keep up with training and education, we will have a chance to help humanity. It is a dilemma that demands more research and better understanding of the problem, which underscores what we at Einstein and Montefiore are all about: We are a socially responsible institution that thinks long and deep about our place—not just in the local community but in the world at large. I am very proud to be part of it.