CLEVELAND – The Cleveland Clinic unveiled the 3rd annual version of its wildly popular Top Ten list of medical innovations on the last day of its Medical Innovations Summit Wednesday. The list of breakthrough devices and therapies was selected by a panel of Cleveland Clinic physicians and scientists. The innovations touch on avian influenza, electronic medical records, and various minimally invasive surgeries to treat uterine fibroids, to repair heart valves, and to remove organs through the body's natural orifices.

As usual, the selection process for nominating technologies was quite rigorous. Four major criteria served as the basis for qualifying and selecting the Top 10 Medical Innovations. Nominated innovations were required to:

• Have significant potential for short-term clinical impact (either a major improvement in patient benefit or an improved function that enhances healthcare delivery).

• Have a high probability of success.

• Be on the market or close to being introduced.

• Have sufficient data available to support its nomination.

A total of 60 staff representing a cross-section from every major medical field at the Cleveland Clinic, as well as operational leaders, were interviewed. From this list, nearly 100 medical technologies were nominated for consideration.

The AlixPartners (New York) advisory firm helped pare that list down to about 30 technologies that were presented to two independent panels of Cleveland Clinic physicians. These two panels then debated and voted on their own Top Ten and then in a combined process came up with the final list.

Here are the Top Ten medical innovations for 2008, from last to first:

10. Private Sector National Health Information Exchange. A comprehensive system of electronic health records that link consumers, general practitioners, specialists, hospitals, pharmacies, nursing homes, and insurance companies is in the process of being established. Primarily a private-sector effort, this computerized system has the potential to replace paper-based medical files with digitized records of patients' complete medical history.

While presenter James Young, MD, chairman of the academic department of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (Cleveland), acknowledged that electronic medical records have been a "tough sell" to older traditional more classic caregivers, he noted that "we are moving dramatically and very rapidly with the youth of our country into a totally electronic communication world."

9. Doppler-Guided Uterine Artery Occlusion. Fibroid tumors occur in upwards of 40% of women older than 35, triggering pelvic pain, pregnancy complications, and heavy bleeding. There is a new, non-invasive approach to treat fibroids called Doppler-guided uterine artery occlusion, or DUAO.

Presenter Eric Jelovsek, MD, assistant professor of surgery in the section of urogynecology and female pelvic reconstructive surgery, department of obstetrics and gynecology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, said that this procedure can allow women to have these fibroids removed and still keep their uterus. "If a woman is suffering from these disorders but wants to potentially have another child or two, this would be one of the only alternatives that would potentially be available," he said.

8. Integration of Diffusion Tensor Imaging (Tractography). Diffusion tensor imaging (DTI) is a new technology that allows neuroscientists to non-invasively probe the long-neglected half of the brain called white matter, with its densely packed collection of intertwining insulated projections of neurons that join all four of the brain's lobes, allowing them to communicate with each other.

"This really has revolutionized the way we approach brain surgery," said presenter Gene Barnett, MD, professor and director of the Brain, Tumor & Neuro-Oncology Center in the clinic's Neurological Institute. I can . . . map out any patient's individual nerve fibers and determine beforehand whether they are a likely candidate for surgery and what type of surgery I would do."

7. LESS and NOTES applications. LESS (laparoendoscopic single-site surgery) takes laparoscopic surgery to an entirely new level by reducing the process to a small cut in the belly button. NOTES (natural orifice transluminal endoscopic surgery) bypasses normal laparoscopic incisions altogether. Instead, the surgeon gets to an appendix, prostate, kidney, or gallbladder through one of the body's natural cavities, such as the mouth, vagina, or colon.

Mihir Desai, MD, director of the Center for Endourology and Stone Disease, Glickman Urological and Kidney Institute said that LESS and NOTES both "offer the possibility of doing complex intra-abdominal and even thoracic reconstructions through a single or a no scar approach."

6. New Strategies for Creating Vaccines for Avian Flu. A newer vaccine approach that uses a mock version of the bird virus called a virus-like particle (VLP) may offer a better solution to protect people against infection from the deadly avian virus.

5. Percutaneous Mitral Valve Regurgitation Repair. Using a tiny barbed, wishbone-shaped device, the heart is fixed non-surgically from the inside out. A catheter is carefully guided through the femoral vein in the groin, up to the heart's mitral valves. The clip, in this case the MitraClip from Evalve (Menlo Park, California), on the tip of a catheter is then clamped on the center of the valve leaflets, which holds them together and quickly helps restore normal blood flow out through the leaflets.

Marc Penn, MD, PhD, a staff cardiologist at the clinic's Heart & Vascular Institute, said that this device will be "a significant game changer" for patients who aren't candidates for open heart surgery and could provide them with "symptomatic relief."

4. Multi-Spectral Imaging Systems. The imaging system is attached to a standard microscope, where researchers can stain up to four proteins using different colors and look at tissue samples with 10 to 30 different wavelengths, allowing for the accumulation of more information than is currently available. This helps researchers to better understand the complicated signaling pathways in cancer cells, and to develop more targeted therapies, which might allow physicians to better personalize treatment for individual patients.

"This technology is going to allow us to take personalized medicine to an entirely different level," said presenter Jennifer Hunt, MD, section head, surgical pathology in the clinic's department of anatomic pathology. "I would say it's not just a step, it's a leap," she added.

3. Diaphragm Pacing System. Four electrodes are connected to the phrenic nerves on the diaphragm. Wires from the electrodes run to and from a control box about the size of two decks of playing cards worn outside the body. When the electrodes are stimulated by current, the diaphragm contracts and air is sucked into the lungs. When not stimulated, the diaphragm relaxes and air moves out of the lungs. "I think it's an important innovation in that it really offers a quality of life to patients who are otherwise ventilator-dependent," said Penn.

2. Warm Organ Perfusion Device. Once a heart becomes available for transplant, surgeons have just four hours before the organ begins to decay. This device, though, recreates conditions within the body to keep the heart pumping for up to 12 hours.

"This is potentially really going to change the way we do heart transplantation," said Tomislav Mihaljevic, MD, a staff surgeon at the clinic's Heart & Vascular Institute. He said it allows a surgeon to extend the distance from where you can accept a donor heart and also to inspect hearts that the doctor might otherwise not accept and put them to use. He said the device also has promise in other solid organ transplants with the kidney, liver and lung.

1. Use of Circulating Tumor Cell Technology. A blood test that measures circulating tumor cells – cancer cells that have broken away from an existing tumor and entered the bloodstream – has the ability to detect recurrent cancer sooner, while also predicting how well treatment is working and the patient's probable outcome. The test results will allow physicians to better monitor a patient's progress, adjusting treatment if necessary.