CLEVELAND – Every year at the Cleveland Clinic Medical Innovation Summit, a highly anticipated event is the unveiling of the Top 10 list of the technologies that will come to the market and change patient care. This year was no different, with pharmacogenomic testing, which uses a patient's genetic makeup to predict an individual's metabolism of drugs, topping the list, with an eye toward combating the opioid crisis.

"There is a major difference this year compared to prior years," moderator Mike Roizen, chief wellness officer at Cleveland Clinic, said. "In prior years, it seemed like there was always a device or a drug. This year, most of the suggestions were the interface of specialties – that is two things combining ... to make major differences for next year."

Regarding pharmacogenomics, Jennifer Hockings, of the Genomic Medicine Institute, Cleveland Clinic, noted that the technique in and of itself won't solve the opioid crisis. However, it provides a "unique opportunity to select a medication a patient will respond to."

Cancer also played a role in the development of the list, with cancer immunotherapy coming in at No. 4. While immunotherapies for cancer have existed for a while, recent work has looked at new and novel immunotherapeutic targets. Scientists are creating treatments through the concepts of joint therapy and engineered T cells. "As many of you know, lung cancer is a horrible diagnosis for any patient, and this type of therapy has and will continue to transform treatment not only for lung cancer, but for many of the cancers that are out there," said Hetty Carraway, of the Taussig Cancer Institute. The technique has held promise for renal, bladder and liver cancers.

Another technique that took a spot, coming in at No. 10, was RNA-based therapies, which Olga Stenina-Adognravi, of the Lerner Research Institute, labeled "important" and "amazing." Using genetic data at the RNA level can give researchers the ability to intercept a patient's genetic abnormality before it is translated into proteins. Mechanisms of RNA therapy include antisense nucleotides and RNA interference, which can be directed toward Huntington's disease, as well as in cancer and other neurologic diseases, with the hope of treatment by way of alternate genetic data.

AI takes a spot

Coming in at No. 2 was artificial intelligence (AI) and its applications in decision support, image analysis and patient triage. AI currently is helping physicians make better decisions at the point of care, improving the ease and accuracy of viewing patient scans and reducing burnout. For instance, machine learning algorithms have the ability to highlight problem areas on images, aiding in the screening process and quickly sifting through mountains of data. With AI's continued integration into health care, caring for patients has become a matter of working smarter, not harder. Ed Marx, chief information officer, Cleveland Clinic, noted that the technology provides a lot of value, especially in terms of "what we can do for the patient experience." For example, patients can self-triage to help ascertain whether they need to come in for treatment. It can help reduce time to treatment and boost patient engagement. Examples include chatbots, which enable conversations by audio or text methods.

Stroke takes two spots

Stroke-related therapies took two spots on the list, with having an expanded window for acute stroke intervention coming in at No. 3. Until recently, intervention of a stroke only has been recommended within a limited window of time – six hours. However, new guidelines, released in January, suggest an expanded window for treatment and clot removal. "We do recognize, of course, that the mantra in stroke is time is brain," said Shazam Hussain, director at the Cerebrovascular Center, and it is essential to treat patients quickly. But what about patients who experience a stroke while sleeping? Previous guidelines had placed limitations on which patients could be treated. Now, advanced imaging techniques with CT and MRI can help select those patients with brain to save – even 12, 24 or 36 hours after a stroke.

Another stroke-related device that made the list, coming in at No. 7, was the hemorrhage scanning visor, which can detect bleeding in the brain. A diagnostic tool, the visor for prehospital hemorrhage scanning serves to speed up diagnosis and time to treatment. Mark Bain, of the neurological institute, Cleveland Clinic, noted that it's difficult to diagnose strokes. In Cleveland, there are mobile stroke units, allowing for stroke diagnosis in the ambulance. "In a lot of communities, in a lot of rural centers, we can't do that," he noted.

The technology, which received clearance in January, has a 92 percent accuracy rate in determining whether a patient is having a large stroke or a large bleed in the brain. It is expected to be commercialized next year, and Bain predicted that in the next year or so, one could expect to see this technology in ambulances.

"I don't think it's going to replace mobile stroke units," said Bain, "That's really the holy grail, getting an ambulance with imaging capabilities to the patient." The goal is to get the visor as inexpensive as possible, perhaps allowing for its use in public places, such as shopping centers.

3D printing

Also making the list at No. 5 was 3D printing for patient-specific products, which can lead to greater acceptance by the body and positive outcomes. Recent work includes the creation of external prostheses and cranial implants. In addition, clinicians can create a 3D model of a patient to gain insight into his or her anatomy, enhancing surgical planning. Tom Gildea, of the respiratory institute, Cleveland Clinic, labeled it a remarkable tool. "For a better part of 20 years, we've been figuring out ways to use it in health care and health care delivery systems, looking at everything from drug delivery, to replacement parts, even creating new organs."

No. 6 was medical education through virtual and mixed reality. "We've been doing this for almost two years now," said Neil Mehta, of the education institute, who noted that it has helped in viewing hard-to-see anatomy. Mehta opined that medical education has not changed in the last 300 years. "We usually spend two years studying books in classrooms, trying to understand why we're learning what we're learning, and [subsequently] trying to remember what we learned two years ago and apply it to real patients." Having a virtual patient can prove useful, as students can see the various structures brought to life. That can be accomplished either in the classroom or remotely.

No. 8 on the list was the use of robotics in surgery. Jihad Kaouk, director at Center for Robotic & Image Guided Surgery, noted robotics are not new in health care, and have been in use since 2000. "What's new is really the spread of robotics all over the subspecialties," he said, pointing to endoscopy and orthopedic surgery. "I think we're still in the early phase of robotics," Kaouk said, noting the increasing amount of available tools – including ones on the smartphone. In addition, there are aspects of robotic surgery that can help clinicians work faster, for example, allowing clinicians to see where instruments are in relation to a tumor.

One device-related innovation was mitral and tricuspid valve percutaneous replacement and repair, which came in at No. 9. Samir Kapadia, of the Heart & Vascular Institute at Cleveland Clinic, noted that the procedure's use could lead to fewer hospitalizations for heart failure patients. He expressed hope that the therapy could reduce cost.

"We all are very, very excited that for the first time, we are able to treat not just the aortic valve, but the mitral and tricuspid valves percutaneously to replace and repair," Kapadia said. He noted that the minimally invasive mitral valve repair device Mitraclip, from Abbott Park, Ill.-based Abbott Laboratories, is seeing routine use. Abbott recently revealed positive two-year pivotal data for Mitraclip at the Transcatheter Cardiovascular Therapeutics meeting in San Diego, as well as publishing it simultaneously in the Sept. 23, 2018, issue of The New England Journal of Medicine. It won the FDA's nod in 2013 for primary mitral regurgitation.