ARTIFICIAL INTELLIGENCE Transforming the way heart disease is diagnosed and treated

FROM FAR AND WIDE Peter Creativity and a multidisciplinary approach lure top-flight talent

THE EVOLUTION OF CARDIAC IMPLANTS Harnessing the power of Munk mechanical hearts and stem cells Cardiac Centre

THE FUTURE IS DIGITAL

DM182487_PgOFC_PMCC_FALL_2017.indd 1 2017-10-13 9:55 AM 76204_PMCC_Ruben_SponsorAd_ART.qxp 2017-09-20 11:24 AM Page 1

Peter Munk THE JEFF AND HONEY RUBENSTEIN FAMILY AND EXPORT PACKERS LIMITED ARE Cardiac Centre Winter 2018 PROUD TO HELP POWER WORLDLEADING INNOVATION AND RESEARCH AT EDITOR-IN-CHIEF THE PETER MUNK CARDIAC CENTRE. Steve Tustin

ART DIRECTOR Frank Perito

CONTRIBUTORS Chris Atchison Bryan Borzykowski Jennifer D. Foster Judy Gerstel Mary Gooderham David Israelson Marjo Johne Daina Lawrence Shannon Moneo Kira Vermond Shelley White

All photography by Tim Fraser, unless otherwise noted. 8 20

GLOBE EDGE 32 48

Jon Banack MANAGING DIRECTOR

Sean Stanleigh MANAGING EDITOR

Liz Massicotte PROGRAM MANAGER

Sally Pirri DIRECTOR, PRODUCTION, THE GLOBE AND MAIL

Isabelle Cabral PRODUCTION CO-ORDINATOR, THE GLOBE AND MAIL ALSO A P R O V E D B Y

3 When Drs. Harry Rakowski and Barry Rubin created the PMCC Innovation Committee, they hoped 6 Artificial Intelligence and cardiac diagnostics it would become a major influence on health care in 8 Heart valve evolutions PETER MUNK Ontario. With over 40 projects approved, their dream CARDIAC CENTRE of impact is being realized – and then some 11 Fellows and the ‘PMCC Way’

magazine is designed 14 Pacemakers keep us going 1 . 2 5 " and produced by 20 Containing more than 25,000 blood and 18 New ways to mend a broken heart

Globe Edge tissue samples, the PMCC Biobank is being used 22 Mechanical hearts buy time Content Studio. to help discover new treatments for an array of

24 New imaging improves lives

e d n s a y S p t m b r 2 0 , 1 7 cardiovascular diseases Printing and pre-press 26 Advances in virtual care 7 6 2 0 4 / U n i v e r s t y H a l h N w o k N e x t I s u W

P M C a g z i n e by DM Digital+1 32 Surviving a complex congenital heart defect at U H N - 1 7 0 28 Treating aortic disease birth is just the first step. As this patient matures, it f u l p a g e = 9 " x 1

4 C 34 Ensuring new devices are safe takes a specialized team of doctors and nurses to provide the lifelong care necessary for survival 36 Enabling global education i n s e r t o d a c o l u r a d s i z e p u b l i c a t o n d o c k e t / l i n a d n u m b e r fi l e r a s d 38 Attracting premium talent EXPORT PACKERS COMPANY LIMITED 48 Drawing inspiration from his mother-in-law and 41 Right app for the times Leaders in Global Food Distribution since 1937 petermunkcardiaccentre.ca his dog, Dr. Kieran Murphy came up with the idea 44 e-counselling about lifestyle exportpackers.com of harnessing anti-oxidants to reduce the harmful effects of life-saving radiation for patients, doctors 46 Conserving precious blood supplies and others exposed at work, such as flight crews 50 Bringing innovation to the world

1

DM182487_Pg01-50_PMCC_FALL_2017.indd 1 2017-10-13 9:36 AM DM182487_PgIFC_PMCC_FALL_2017.indd 1 17-10-06 1:23 PM The Peter Munk Cardiac Centre Innovation Committee

More than 40 projects have been launched so far and some of these projects, all funded by philanthropy, have significantly changed and influenced the way health care is delivered in Ontario and across Canada

by Shelley White We preserve wealth. You preserve health.

We salute you for preserving what matters most. Gluskin Sheff congratulates the Peter Munk Cardiac Centre and The Globe and Mail for creating a stage to showcase the accomplishments of Canada’s premier cardiac centre. William Charnetski is a big believer in “celebrating our champions” here in Ontario. But touting our homegrown accomplishments is something we, as Canadians, don’t always do well enough, says Ontario’s chief health innovation strategist. ¶ “It feels like with anything other than hockey, we seem to require that people go elsewhere and establish themselves, [to] gain the inherent credibility Wealth & Risk Management that makes them more popular at home,” he says. ´ www.gluskinsheff.com Invested in your prosperity @GluskinSheffInc 416.681.6000

Winter 2018 3

DM182487_Pg01-51_PMCC_FALL_2017.indd 3 2017-10-06 10:59 AM 0180GLSDM182487_Pg02_PMCC_FALL_2017.indd PMCS Full Page Ad v3.indd 1 2 2017-07-2717-10-06 1:252:30 PMPM The Peter Munk Cardiac Centre (PMCC) Innovation Committee was created by Dr. Barry Rubin, right, and Dr. Harry Rakowski. They were looking for a “unique and nimble process” to evaluate Talking up the province’s health-care success stories has been a and launch innovative priority for Mr. Charnetski and his team since he took on the newly proposals to impact cardiac and vascular created position in Ontario’s Ministry of Health and Long-Term Care care. William Charnetski, in 2015. So when he attended a meeting of the Peter Munk Cardiac opposite page, is Centre (PMCC) Innovation Committee, Mr. Charnetski knew he was Ontario’s chief health witnessing an exciting Ontario health-care story worth celebrating. innovation strategist. “I love the structure,” says Mr. Charnetski of the dynamic committee He says the PMCC that’s been called the Dragons’ Den of health care. “It’s obviously committee is an exciting [comprised of] smart, passionate, hard-working people. The notion Ontario health-care story that the hospital’s doing it this way is important, and it’s important for worth celebrating. us to showcase the work that’s being done.” Created in 2012 by Dr. Barry Rubin, Medical Director of the PMCC, and cardiologist Dr. Harry Rakowski, E.D. Wigle Chair in Hypertrophic Cardiomyopathy Research, the PMCC’s Innovation Committee reinvented the wheel when it comes to funding health- care projects. Instead of small groups of doctors making funding decisions, the committee is made up of more than a dozen people of diverse backgrounds and skill sets, and several committee members CHANGES come from outside of the medical field entirely. Surgeons, scientists ON THE WAY and cardiologists mix with hospital administrators, entrepreneurs and business leaders on the committee, and everyone has an equal vote. Though the core philosophy of the Submissions are accepted quarterly instead of annually, and over PMCC’s Innovation Committee will 1,000 employees at the PMCC can submit a proposal, from nurses to continue as is, Dr. Rakowski says there radiologists to anesthesiologists. are changes planned to improve its The PMCC’s Innovation Committee is an exciting concept that could effectiveness and efficiency. The PMCC provide a model for other health-care organizations to follow, says Mr. has recently acquired some unique Charnetski. pieces of equipment, he says, so they “To have it organized in the way that the committee is organized plan to incorporate specific categories of is potentially really powerful, when you’re one of Canada’s biggest funding to help understand how this new hospitals,” he says. technology can be best utilized. He applauds the fact that the PMCC’s Innovation Committee For example, the PMCC acquired a PET- combines the expertise of those in the health-care realm with those MRI scanner, which allows physicians to in the business world. see a fused image of both an MRI (which “I truly believe that the optimal solutions to the challenges that face We’re going to look at your research project and improve the design. helping the recipients be self-sufficient. looks at structure) and a PET (which the health-care system will come from the collaboration of the public We’re going to look at your budget and streamline, so you can achieve The PMCC’s Innovation Committee is funded in its entirety by looks at metabolic function). “There are certain diseases where that sector and private sector,” says Mr. Charnetski. “That’s a critical success the same thing but spend less money. We want you to succeed.” generous philanthropic donors who put their put their trust in the panel information may be vitally important to decision-making, so we’re factor for me.” Marnie Weber has been a member of the PMCC’s Innovation to direct funding to projects with opportunities for greatest impact. specifically funding some of those [projects],” he says. Committee since its inception. Ms. Weber is Executive Director, More than 40 projects have been funded by the PMCC’s Innovation The PMCC will also soon be getting a leading-edge piece of equipment A ‘UNIQUE AND Strategic Developments, at University Health Network (UHN), and Committee so far, some of which have gone on to influence and even in partnership with an Israeli company that produces holographic 3-D NIMBLE PROCESS’ she says that it can be challenging to take an innovative idea from change practice in Ontario. One example is a blood conservation project imaging. The machine can take any three-dimensional image set – from concept to changing practice. pioneered by anesthesiologist Dr. Keyvan Karkouti (see story on page echocardiography or MRI, for example – and create a holographic When Drs. Rakowski and Rubin came up with the idea for the PMCC’s “We’re a big research engine in Canada, but that’s insufficient to bring 46). An initial seed investment of $80,000 resulted in multinational, image of the heart. The PMCC will be the first in the world to use the Innovation Committee, they were looking for a “unique and nimble something into clinical practice,” says Ms. Weber. “How do you actually multicentred trials, additional funding and an additional generation device for a cardiac application, says Dr. Rakowski, and so they are process,” says Dr. Rakowski. get it spread across other organizations in Ontario? And how do we of studies, says Dr. Rakowski. soliciting projects to help them discover its potential benefits. “The idea was to get not just physicians, but [also] other people who ensure that it becomes a core part of the health-care system?” “It is saving blood product consumption by about 40 per cent, which Dr. Rakowski says the PMCC’s Innovation Committee may expand were non-physicians – allied health-care professionals and business People who like to research and are driven to advance the practice translates into fewer complications of blood product delivery and its research in areas such as information technology, genomics and leaders – to really look at [ideas] and ask, ‘Is this truly innovative?’” of medicine are not necessarily entrepreneurially minded, says Ms. health-care cost savings,” he says. personalized (or precision) medicine, targeting treatments to individual he says. “The key things are: Is it going to have [an] impact? Is that Weber. And that’s why the mix of people on the PMCC’s Innovation Another example is an “anti-oxidant cocktail” created by UHN patients. And the makeup of the committee will also be changing soon, impact measurable? And is it cost-effective?” Committee is key to its success. interventional neuroradiologist Dr. Kieran Murphy that reduces the with a venture capitalist joining this year. While traditional granting bodies require pages and pages of detailed “The committee is formed both with very smart business people, but negative effects of X-rays on DNA (see story on page 48). Like Dr. Regardless of these moves forward, Dr. Rakowski says the committee proposals, applicants to the PMCC’s Innovation Committee must only also people who are keeping an eye [as] to what’s relevant to patients Karkouti’s project, that initial seed funding resulted in additional will remain true to its original vision. It’s important for the committee answer 10 questions, plus commit to a cost-effectiveness study. And and what’s relevant to society,” she says. “[The medical professionals] research studies, says Dr. Rakowski. Now, Dr. Murphy has produced to retain its independence, he says: “Not being beholden to anybody while most funding organizations are proud of the fact that they reject on the committee are great educators, clinicians and researchers. And a product with “commercial potential and tremendous health benefit or having institutional bias or favouritism to anybody.” Dr. Rakowski 85 per cent of proposals, says Dr. Rakowski, he and Dr. Rubin wanted the laypeople bring the perspectives of the general public and what for low cost.” notes that even committee co-founder Dr. Rubin is treated the same to buck that trend. matters to patients or family caregivers, as well as their own business The PMCC’s Innovation Committee is a model that can be replicated as everyone else – one his proposals was recently sent back to the Instead of simply turning away unsuccessful applicants, the committee investment backgrounds. So you get this great dynamic of people trying elsewhere because it runs on philanthropy, says Ms. Weber. Interest has drawing board. provides constructive input and guidance, helping them improve their to understand and see where this idea can go further.” been coming in from government and other health-care institutions, “We have a vision, and we are committed to it,” says Dr. Rakowski. “If proposal and possibly submitting again a few months later. The committee spends about $1-million per year, raised through as well as elsewhere in the UHN. you lose that intimacy or the nimbleness, then you simply become an “Our goal is to fund as many good ideas as we can,” he says. “So we’re philanthropy, says Dr. Rakowski. The amount given to each applicant “Other programs within the UHN have said, ‘If cardiac can do it, we administered bureaucracy. And [what helps to make] this committee going to help you improve your proposal, we’re going to work with you. varies, but they look at the funds as seed money, with the end goal of should have something similar, too,’” she says. unique are those qualities, which we obviously don’t want to lose.”

4 Peter Munk Cardiac Centre Winter 2018 5

DM182487_Pg01-51_PMCC_FALL_2017.indd 4 2017-10-13 9:57 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 5 2017-10-06 10:59 AM A diagnosis of coronary artery disease usually comes after a series of “You can use the AI approach to pinpoint which patients face potentially procedures, including blood tests, exercise to reproduce symptoms, an lethal events, and bring them to the hospital before that happens,” says Dr. electrocardiogram, a chest X-ray and, finally, cardiac catheterization, where Rubin. “So you’re managing patients outside the hospital and using the a thin tube is inserted through the heart’s blood vessels to check blood flow real value of AI to predict and prevent these lethal events.” and function in various parts of the organ. The great wealth and quality of digital health and research data at the It can take weeks, even months, for each patient to go through these PMCC are critical to the success of the centre’s AI goals, says Dr. Rubin. The gold-standard procedures. PMCC recently flowed six of 47 disparate clinical and research databases But this decades-old way of diagnosing coronary artery disease could into a vast “data lake,” and it is now working to bring the remaining soon be a thing of the past, thanks to artificial intelligence (AI) technology. databases into the same central reservoir. “With our technology, you just lay down, take off your shirt and, with a By integrating all this data – blood tests, clinical notes, X-rays, hand-held, battery-operated device, your doctor can take a three-minute ultrasounds, CT and MRI scans, pathology slides and genetic information recording that collects 10 million data points,” explains Don Crawford, – in one location, clinicians and researchers can use AI to discover potential president and CEO of Analytics 4 Life Inc., a Toronto-based company causes of heart disease. These discoveries, in turn, can lead to new cures. focused on artificial intelligence-based medical devices. “This data is then “For example, if we have data on 10,000 patients with a narrow heart sent to a cloud storage device, and from there our computers take that data valve, and it turns out that 2,000 of these patients have a similar gene and create a three-dimensional image of the heart, along with a detailed mutation, we could determine how that gene works and develop new report,” explains Mr. Crawford. therapies that would prevent the heart valve disease from ever developing “By the time the patient has their shirt back on, the physician has in patients with that mutation,” says Dr. Rubin. already received the report on their computer. And based on this report, Toronto is one of the two epicentres for thought leadership in AI – the they can let their patients know whether or not they need to go to the other place is Silicon Valley in California – and boasts a robust ecosystem cath[eterization] lab.” for AI- and digital-based health-care innovations, says Ying Tam, head The Analytics 4 Life technology, currently being tested in a dozen of health at the venture services for MaRS Discovery District, a Toronto hospitals in the United States, is at the leading edge of artificial intelligence innovation hub that connects entrepreneurs, business experts, researchers, in cardiac care – an emerging field of science that’s set to change the way educators and social scientists. cardiovascular diseases are diagnosed and perhaps even treated. He points to Ontario companies such as Cloud DX and Deep Genomics, ARTIFICIAL At the University of Nottingham in England, researchers used machine which use AI and machine learning to diagnose disease and design more learning – where AI algorithms trained themselves – in order to find targeted therapies. patterns to predict which patients would have their first heart attack While AI champions continue to innovate in health care, it will likely over the next 10 years. After scanning close to 300,000 patient records, take years before many of these new technologies are adopted in clinical the researchers found that the AI algorithms did significantly better in practice, says Mr. Tam. Regulations that govern medical technology are INTELLIGENCE predicting heart attacks than assessments based on the commonly used complicated, says Mr. Tam, and could work against the very nature of American College of Cardiology/American Heart Association guidelines. artificial intelligence. For instance, when an organization such as the U.S. In India, a start-up called Cardiotrack recently rolled out a technology Food and Drug Administration approves a medical solution, it does so platform that uses a hand-held device, cloud storage and artificial based on a specific information package. With AI, information continues intelligence to capture and analyze electrocardiogram signals for specific to change as the underlying algorithms learn from existing and new data. LAUNCHES A heart conditions. “The possibilities with artificial intelligence are truly exciting,” says Brian Golden, Sandra Rotman Chair in Health Sector Strategy at the University of Toronto (U of T) and the University Health Network (UHN) and vice- NEW ERA IN dean of professional programs at U of T’s Rotman School of Management. “What we do with the Vector [Institute] “The ability to instantly recognize patterns and make sense of data from will be the model for what it does these patterns will improve diagnosis speed and quality, reduce wait times, improve health outcomes and reduce costs.” subsequently with cancer, neurosciences In Canada, the stage is set for AI to transform how heart disease is and other health disciplines.” CARDIAC CARE diagnosed, treated and managed. And the Peter Munk Cardiac Centre (PMCC) is right in the centre of this exciting transformation, powered by Dr. Barry Rubin, Chair and Program Medical Director, PMCC digital data, ubiquitous connectivity and intelligent machines. From diagnostics Armed with a $100-million donation from the Peter and Melanie Munk Charitable Foundation, the centre has forged a partnership with U of T’s to therapeutics, Vector Institute for Artificial Intelligence, which was launched last March Nevertheless, AI solutions have already been proven in other areas to advance deep learning research and develop world-leading AI talent. in health care. Dr. David Jaffray, Senior Scientist at Princess Margaret “This is the first formal health-care partnership that the Vector Institute Cancer Centre in Toronto, points to the use of algorithms at the hospital artificial intelligence has engaged in, and we anticipate that what we do with the Vector to automate the design of treatments for cancer patients. [Institute] will be the model for what it does subsequently with cancer, “The technology is very attractive because it allows us to design the is set to change the neurosciences and other health disciplines,” says Dr. Barry Rubin, Chair treatment sooner, treat patients sooner and even ensure that the treatment and Program Medical Director, Peter Munk Cardiac Centre plans follow the appropriate protocols,” he says. Together, the PMCC and the Vector Institute will build an AI team This level of AI-enabled efficiency can, in the future, also help hospitals way cardiovascular that includes a lead computer scientist, software engineers and PMCC to optimize the use of their resources, while ensuring the best outcomes clinicians. This team will work to identify heart problems that can be solved for patients, says Dr. Rubin. diseases are identified through AI and machine learning. “If we had complete data on all of our patients, we could use AI to “We will use predictive models and decision support to tailor patients’ care predict which patients that had heart valve surgery would stay in hospital and treated to their unique clinical and genomic traits,” says Dr. Rubin. “We will use three days or 10 days after their operation,” he says. “Using this AI-based natural language processing to communicate with patients in real time, no approach, we will be able to better plan and better utilize our health-care matter what language they are speaking. Taken together, this will improve resources.” By Marjo Johne the efficiency of health-care delivery, outcomes and patient satisfaction.” Having cemented its partnership with the Vector Institute, the PMCC What will AI-supported cardiac care look like to patients and health- must now work to integrate AI into practice – an undertaking that requires care professionals? Dr. Rubin paints a sample scenario, where doctors a shift in mindset around patient care. can remotely monitor patients with conditions such as abnormal heart “We will need to train clinicians and students at the PMCC to work in rhythms and then bring to the hospital those who are identified as at risk environments where AI-based predictions will inform treatment decisions of death or serious heart damage, based on AI algorithms that can analyze and the management of patients,” says Dr. Rubin. “There’s no question that

Illustration: Made by Emblem billions of biological and research data points. AI and machine learning are the future.”

6 Peter Munk Cardiac Centre Winter 2018 7

DM182487_Pg01-50_PMCC_FALL_2017.indd 6 2017-10-13 9:45 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 7 2017-10-13 9:45 AM l Ouzounia Osten e David rt James Cu Horlick ara n ark ron be sim ic M M Ti Ro a Er r. r. r. r. n r. D D D D o D Heart valve innovations: Novel procedures and devices keep pumping in

Transcatheter Aortic Valve Implantation (TAVI) has changed the game in heart valve care and saved the lives of patients who were considered too high-risk for surgery. With TAVI now well-entrenched in clinical practice,

cardiac doctors are looking out for the next big thing in heart valve repair and replacement like device into the centre of the valve. The “We will be looking for specific patient or acquired heart defects. “Right now, there’s foam-filled polymer balloon – also referred traits, as well as specific mitral valve anatomy, TAVI funding in Ontario only for high-risk by Marjo Johne to as a “spacer” – is implanted through a vein including the amount of calcium in the patients. We hope this will change as more in the upper chest using a catheter – a similar valve leaflets, and whether the opening and and more compelling positive data supporting technique to implanting a pacemaker. the geometry of the valve and surrounding TAVI becomes available. For the last several “Will it work? I think it will help to reduce the structures are optimal,” she says. “Right now, years, we have been performing TAVI without problem, but I’m not sure if it will completely there really isn’t anyone in the world with a general anesthetic, under minimal sedation fix it,” says Dr. Robert James Cusimano, a enough experience in this type of procedure, and without any surgical incisions in the groin. Game-changing. Life-saving. Grand slam. says Dr. Ouzounian. “We’ve been doing TAVI left ventricle to leak backward into the lungs. cardiac surgeon, and clinical researcher at and it is still experimental.” The procedure typically takes less than an hour. Phenomenal. These are just some of the since 2006 and are recognized nationally as a When a patient has severe mitral valve the PMCC, who holds the David and Stacey Recovery from TAVI in 2017 has become much words doctors and patients use to describe centre able to tackle cases of great complexity. regurgitation, they may become breathless, Cynamon Professorship in Cardiovascular Percutaneous pulmonary easier for the patient. They can be at home, Transcatheter Aortic Valve Implantation That’s important to companies that are and the heart becomes enlarged over time. Surgery Innovation and Education. “That’s valve implant recovering in 24 hours.” (TAVI), which replaces a damaged heart valve developing these new technologies. They want Traditionally, this has required open heart what we are looking to find out.” The PMCC recently started assessment of a with a replacement valve inserted through a an experienced group, who work well together surgery to repair or replace the valve. The Often overlooked, the tricuspid valve is second-generation device to fix pulmonic valve In search of the next big thing small incision in the leg. to achieve outstanding results with novel PMCC has been an international leader a complex structure that resembles three disease, often related to a congenital heart What could be the next game-changer after TAVI has been a godsend for patients technology – there’s just too much at stake. in pioneering surgical techniques for this parachutes with strings attached to the heart. condition where blood may not flow properly TAVI? Dr. Paul Fedak, a researcher for the considered too high-risk for open heart surgery. The expertise we bring to the table is critical to condition. In some cases, because of previous Tricuspid valve regurgitation usually doesn’t from the heart to the lungs because the valve Heart and Stroke Foundation of Canada and The results so far have been outstanding, with achieving great results for our patients.” heart surgery, poor pump function or other trigger any symptoms until the condition between the right ventricle and the pulmonary a professor in the Department of Cardiac an estimated 20 per cent reduction in deaths Having a robust and sophisticated clinical medical problems, patients are just too sick or becomes severe. At its worst, it can lead to heart artery is defective. Sciences at the University of Calgary, says the a year after the procedure. Large randomized infrastructure has also been critical in too weak to tolerate open heart surgery. failure, severe swelling of the legs and fluid in Like TAVI, the new device – a collapsible next big breakthrough in valve care is likely studies on high-risk and moderate-risk patients gaining early access to new innovations, says This is where the MitraClip comes in. Many the belly, says Dr. Cusimano. cylinder with scalloped edges – is inserted into to come from tissue engineering innovations. have also shown the benefits of a procedure Dr. Mark Osten, a PMCC cardiologist and lead patients who cannot tolerate open heart “It can become very dangerous when you the dysfunctional valve through a catheter. “I think in the future, we will have replacement that can put the patient back home the next investigator into new structural heart disease surgery may be helped by the clip. don’t fix the problem,” he says. “The Forma “Patients with pulmonic valve disease tend valves that are designed for each patient out of day. devices. The clip is implanted through a catheter System – which is still an investigational to develop problems when they’re very young, their own cells and tissues,” he says. “These “TAVI completely revolutionized how we take He points to the PMCC’s state-of-the-art based technique via a vein in the leg. The therapy and not available for use outside a trial so they often have operations as babies or will be real game-changers because you’ll be care of patients with aortic valve disease,” says operating rooms, which include two hybrid MitraClip is a V-shaped clamp with movable setting – could be one way to do this.” children, and these procedures eventually less prone to infection and won’t need blood Dr. Maral Ouzounian, cardiac surgeon at the rooms – one that features a CT scanner arms that can open and close to pinch leaking fail in adulthood,” says Dr. Osten. “We have thinners, the valves will never break down and Peter Munk Cardiac Centre (PMCC). “Before and fluoroscopy machine and another that valve leaflets together, ensuring that they meet, Transcatheter mitral valve had devices for a particular anatomic subset when they’re used in a younger patient, they’ll TAVI, patients who were frail or elderly would incorporates diagnostic imaging equipment – reduce leaking and restore proper functioning replacement of these patients for almost a decade, and the have the potential to grow as the patient grows, not be sent to a surgeon for assessment because that support more complex procedures. of the valve. Tissue eventually grows over the The success of TAVI has encouraged long-term results have been very rewarding. which is a huge deal.” of concerns they would not make it through “The companies that make these new clip to further support the clip. Patients can researchers to push for similar advances in The next generation of devices, which are In the meantime, the research and clinical surgery. TAVI has really changed that – we technologies recognize that we have the often be discharged home the next day. minimally-invasive mitral valve replacement. now being evaluated in trials, will be able to teams at the PMCC continue to examine new regularly perform TAVI on patients beyond infrastructure, the support of our institution The MitraClip can help patients with a A number of medical device manufacturers address a much larger population of patients and emerging technologies in heart valve care. the age of 90 [years] – and most often, they and an incredible breadth of experience in severely leaking mitral valve who are not have developed transcatheter options for this with this problem. The potential to replace Drs. Osten and Horlick recently travelled go home within a day or two of the procedure.” cardiac and structural heart disease,” says Dr. surgical candidates, says Dr. Tirone David, procedure, says Dr. Ouzounian. the pulmonary valve, through a small vein to Israel as part of a project to evaluate the With TAVI now well-entrenched in clinical Osten. “We do some of the highest-risk cases cardiovascular surgeon and the Melanie Munk “We are still in the early days of mitral valve in the leg, in most patients during their most usefulness of holographic imaging of the heart practice, doctors and scientists are eyeing the in the country.” Chair in Cardiovascular Surgery. replacement compared to TAVI,” she says. “In productive years – is just around the corner.” during a medical procedure. next wave of innovations in heart valve care. So what new heart valve innovations are the “We use the MitraClip for patients who are many ways, TAVI is easier because the aortic The three-dimensional digital image, PMCC doctors testing these days? The latest not operative and are symptomatic” he says. valve is anatomically more straightforward and Back to TAVI: which floats in mid-air and can be touched, A huge momentum in innovations technologies offer the potential for major “We offer this procedure as palliation, and it has a whole lot of calcium in it to anchor the From revolution to evolution manipulated and even cut up to show the inner TAVI has created a huge momentum in heart improvements in quality of life for patients who does offer relief and improved quality of life for replacement valve.” TAVI continues to evolve in its applications. anatomy of the heart, is a novel technology with valve innovations and has set the stage for otherwise would be in profound heart failure many of our non-operative patients. Surgery A number of medical device manufacturers Dr. Eric Horlick, a cardiologist at the PMCC, potential applications in education and, most future transcatheter valve technologies that or die. Novel technologies have been applied works better, but not everyone is suitable for have developed their own version of sees a future where TAVI is the go-to treatment significantly, as a tool in the operating room are tackling the other three valves of the to each of the four valves of the heart, relieving heart surgery”. transcatether mitral valve replacement. Dr. for most, if not all, aortic valve patients. “Right and catheterization lab. heart through less-invasive procedures. As a leaking and stenotic (narrowed) valves and Ouzounian says she and the other cardiac now, there is more TAVI being done in the “Cardiac imaging plays a major role in recognized leader in heart valve care, the PMCC improving a patient’s symptoms. Tricuspid valve repair specialists at the PMCC are evaluating one U.S. than conventional surgical aortic valve structural heart disease intervention. has early access to many of these innovations – In the right side of the heart, the tricuspid particular system that is part of a clinical trial. replacement.” If a technology can help us have a greater initially through clinical trials, and then more UP AND COMING: THE LATEST valve – which has three flaps, or leaflets, that “At this point, we don’t know which He points to clinical trials now evaluating understanding of the cardiac and vascular widely after regulatory approval. The PMCC is INNOVATIONS AND APPLICATIONS open and close – regulates the flow of blood transcatheter mitral valve replacement patients who are low-risk for surgery and structures, this will ultimately translate into on the cutting edge of these advances and is one IN HEART VALVE CARE from the right upper chamber (right atrium) technology will be successful. They’re all treating them with TAVI. The PMCC is better decision-making and clinical outcomes of a few centres in Canada routinely providing to the lower chamber (right ventricle). When different, with their own set of advantages and participating in these clinical trials, which are for our patients. With holographic imaging, transcatheter valve repair or replacement for MitraClip the lower chamber is enlarged, the tricuspid risks,” she says. likely to change the way care is delivered to a we will hopefully be able to define the anatomy each of the four valves of the heart. Doctors at the PMCC use a device called the valve stretches and pulls apart, and the flaps Regardless of which technology is used, very common form of valve disease. with more precision and potentially use it to MitraClip to treat patients with severe mitral no longer meet in the centre, causing blood to transcatheter mitral valve replacement is “Operationally, the U.S. has seen greater guide us live through these minimally-invasive Experience and infrastructure key to valve regurgitation, a disease characterized by a regurgitate back into the upper chamber. considered a high-risk procedure, says Dr. adoption of TAVI for moderate-risk patients,” procedures,” says Dr. Osten. “That’s something accessing new technologies distorted left ventricle that stretches the mitral To repair this faulty valve, doctors at the Ouzounian. Because of this, doctors at the says Dr. Horlick, who holds the Peter Munk that’s potentially a game-changer, and we are “To access these innovations, you need a highly valve opening or by abnormalities of the valve PMCC are participating in a clinical trial PMCC are considering patients according to a Chair in Structural Heart Disease Intervention, going to be the first and only hospital in the functional and experienced team with a strong itself that prevent the valve flaps from closing testing a new therapy called the Forma System, detailed experimental protocol, to select those which focuses on research into minimally- world to evaluate it. It will be exclusive to the reputation nationally and internationally,” properly. This gap causes blood flowing into the which involves the placement of a balloon- best suited to the technology. invasive approaches to managing inherited PMCC.”

8 Peter Munk Cardiac Centre Winter 2018 9

DM182487_Pg01-51_PMCC_FALL_2017.indd 8 2017-10-06 10:59 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 9 2017-10-06 10:59 AM Subcutaneous ICD “We have a clear mission to be S-ICD | Protection without touching the heart the No. 1 heart centre in the world.” Fellows also want to study with the PMCC’s many International “superstars” in the field, he adds, such as cardiac surgeon Dr. Tirone David, cardiologist An S-ICD is a subcutaneous implantable Dr. Heather Ross and vascular cardioverter defibrillator. It is designed to fellows come surgeon Dr. Thomas Lindsay. While at the PMCC, fellows provide protection against Sudden Cardiac learn the “PMCC Way,” says to learn the Dr. Rubin. It’s a philosophy Death, without a lead in the heart. that is the cornerstone of the institution and includes three ‘PMCC Way’ pillars: a mandate to work The lead that transfers the impulse from in multidisciplinary teams, a commitment to using the best the device to the heart is not implanted into equipment in the world and an the heart through the blood vessel, like with Hundreds of national and international physicians apply each unremitting focus on innovation. “Lots of people talk about this, the transvenous ICD. The lead of the S-ICD sits year to train with Peter Munk Cardiac Centre specialists in a but we actually walk the walk,” unique program he says. just under the skin, leaving the heart and blood Dr. Rubin says that one of vessels untouched and intact. the goals of the international fellowship program is to teach fellows the PMCC Way in the by Shelley White hopes that they will bring it back to their home institution in Tokyo or Buenos Aires or Bangalore. “The real mark of success is: Dr. Diego Delgado At the Peter Munk Cardiac ‘Did that person ascend to a ICD therapy is a very trustworthy therapy that has prolonged hundreds of thousands of lives. and Dr. Carolina Alba, Centre (PMCC), the world’s best leadership position and then cardiologists from and brightest come together for a start training other people When ICD devices were first introduced in the 1980s, they were implanted in the abdomen. Argentina, were two common cause: to save lives. locally, the way they were trained of the fellows from Walking through the halls of at the PMCC?’” says Dr. Rubin. around the globe the PMCC, it’s not uncommon “That’s when you know you’ve hoping to bring PMCC Later came the transvenous ICD, which is implanted in the shoulder area. The less invasive to encounter groups of really had an impact.” teaching back to their home institutions. international fellows intently Meet four physicians who have subcutaneous ICD (S-ICD) is the latest type of ICD device, introduced in 2008, which delivers discussing a complex case with had that impact since their time staff physicians. These fellows as international fellows at the protection against Sudden Cardiac Death, without touching the heart. hail from all over the globe PMCC: – Asia, South America, the U.S., Europe, Africa – bringing Dr. Diego Delgado knowledge with them and then Cardiologist, Reuben and taking what they’ve learned back Florence Fenwick Family to their home countries. Professorship in the Medical Each year, hundreds of national Management of Heart Failure and international physicians apply to obtain postcertification COUNTRY OF ORIGIN: Argentina training with experienced specialists at the PMCC in areas Dr. Diego Delgado was a such as: adult congenital heart cardiologist in his native disease, cardiovascular surgery, Argentina when he decided vascular surgery and heart failure to further his training and transplantation. While they internationally. He says he was Abdominal ICD Transvenous ICD Subcutaneous ICD learn, the fellows provide much- drawn to the PMCC because the needed manpower to help PMCC transplant program was new, and staff with the day-to-day work of he was looking for a challenge. treating patients. “I was already trained in For more information and real The PMCC’s fellowship advanced heart failure and S-ICD patient stories, visit: program attracts international transplant mechanical devices, physicians because of its so for me it was going to be more www.SICDsystem.com excellent worldwide reputation, of a challenge to help build a says Dr. Barry Rubin, Medical program from scratch, versus Director of the PMCC. going somewhere that was “We are a growing, expanding, already established,” he says. All cited trademarks are the property of their respective owners. CAUTION: The law restricts these devices to sale by or on the order international brand,” he says. After his fellowship, Dr. of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labeling supplied with each device. Information for the use only in countries with applicable health authority product registrations. Information not intended for use in France. 2017 Copyright © Boston Scientific Corporation. All rights reserved. CRM-450307-AA JAN2017 Winter 2018 11

DM182487_Pg01-51_PMCC_FALL_2017.indd 11 2017-10-06 11:06 AM DM182487_Pg10_PMCC_FALL_2017.indd 10 17-10-06 1:24 PM

FV_BG03417_S-ICD_Patient_Advert_9x11_25inch.indd 1 13.07.17 14:35 COUNTRIES OF ORIGIN PMCC FELLOWS FROM AROUND THE GLOBE COUNTRY TOTAL OF PMCC FELLOWS Data compiled from 2001, including 48 participating countries Ireland 7 Belgium 6 Finland 5 New Zealand 5 Spain 5 South Africa 4 Mexico 3 Netherlands 3 France 3 Philippines 2 Delgado, who holds the Reuben and Florence Syria 2 Fenwick Family Greece 2 Professorship in the Medical Management Iceland 2 of Heart Failure, was Sudan 2 invited to stay on at the PMCC, and in the China 2 years since, he has West Indies 1 become an integral part of the institution. Slovenia 1 As a cardiologist and Poland 1 heart failure specialist, Hungary 1 Dr. Delgado says he is a big proponent of the PMCC’s Portugal 1 multidisciplinary approach. Czech Republic 1 “Because these patients are very complex and they Hong Kong 1 are critical in many cases, Norway 1 you need a collaborative team,” he says. That goals Lebanon 1 team can involve nurses, in mind Russia 1 nurse practitioners, social when he Now, Dr. Nambala workers, psychiatrists and applied to be an is passing along Korea 1 physiotherapists, along with international what he learned at surgeons, cardiologists and fellow at the the PMCC to surgeons Thailand 1 radiologists. PMCC: to from India and other Guyana 1 “That’s how the outcomes in train with parts of Asia. “People now supported as a patients with heart failure have Dr. Tirone come and watch what we do female physician St. Lucia 1 improved over the last 10 years, David and here,” he says. “Many times and a mother. “You because of this concept of the learn to do when I get observed I say, ‘I feel like there is Brunei 1 multidisciplinary team.” one particular learned this in Toronto.’” some flexibility to Dr. Matthias Greutmann Two years ago, Dr. Delgado operation. It was the “David balance your work Director of the Congenital Austria 1 helped create a fellowship to Operation” (which is named Dr. Carolina Alba and family life (e.g., leaving Heart Disease Unit, University St. Kitts 1 bring in more fellows from Latin after Dr. David) – a valve- Cardiologist, former LaSorda work to pick up your sick child Hospital Zurich American countries. He hopes to sparing aortic root replacement. Family Fellow from school). And that’s so very Antigua 1 continue to build the fellowship “I was fascinated by that important as well – to work COUNTRY OF ORIGIN: Switzerland program, focusing on bringing operation,” says Dr. Nambala. COUNTRY OF ORIGIN: Argentina happier and reduce the stress.” Trinidad & Tobago 1 in talented people who may “During my training, I used to As someone who now works As a resident at University Romania lack resources in their home always say if there’s one chance Like Dr. Delgado, Dr. Carolina with international fellows (and Hospital Zurich, Dr. Matthias 1 countries. to work with this man, I would Alba began her medical career in was once in their shoes), Dr. Alba Greutmann developed an Nigeria 1 “I value bringing in physicians want it.” her homeland of Argentina. Also says the bonds formed through interest in adult congenital heart he says. “From the beginning, from the Middle East, South Asia Dr. Nambala was at Manipal like Dr. Delgado, her positive the fellowship program are disease and decided to look for everyone was interested in Iran 1 or Central and South America Hospitals in Bangalore at the experiences in the PMCC’s lasting ones. some international training in our opinions. I think that was because I know that we can time and had a colleague who international fellowship program “We establish very good the area. Two of his colleagues extremely important, and create a huge global impact by had trained with Dr. David. my convinced her to stay on after her relationships with everybody had been fellows at the PMCC, so that’s what I brought back to training these people and having The colleague was going to life before.” fellowship was over. who comes here, so everybody he also applied. Switzerland.” over the world.” them go back to their own an international conference During his time at the PMCC “One important aspect of feels engaged,” she says. “I am “It was well-known that Toronto Connecting with other And he is always pleased to see country,” he says. “I’ve seen it.” in Barcelona, Spain, so Dr. from 2006–07, Dr. Nambala the fellowship program at the able to tell you that because is the place to be for congenital international fellows from his former PMCC colleagues at Nambala gave him his CV in had the chance to work with PMCC is that all are treated with I have been a fellow until heart disease,” he says. around the world while at the international conferences, such Dr. Sathyaki Nambala the hopes he could pass it on to Dr. David and see the “David respect,” says Dr. Alba. recently, so I know very well Dr. Greutmann was a fellow PMCC has also been a boon, says as the recent World Congress of Chief cardiac surgeon, Apollo Dr. David. Two months later, Operation” first-hand. “He’s “Fellows and other team the intimate feeling of all the at the PMCC from 2008–10, Dr. Greutmann. Pediatric Cardiology and Cardiac Hospitals, Bangalore Dr. Nambala was on his way to probably the best surgeon I’ve members – no matter what their fellows. And when they move and says he was struck by the “If a patient comes to me and Surgery in Barcelona. Toronto to be an international worked with in my life so far, and position at the hospital – can give back to their countries, we keep “openness” and “spirit” at the tells me, ‘I am going to travel “The whole Toronto group COUNTRY OF ORIGIN: India fellow at the PMCC. that experience is something I an opinion,” she says. “Everybody the connections, which turn into hospital. here or there,’ I’ll say, ‘I know met for a dinner, and it was “I actually landed in December,” don’t think I’ll ever forget,” he is heard here.” opportunities to collaborate with “I always felt extremely someone,’ and I’ll refer them,” very nice,” he says. “It’s like my Dr. Sathyaki Nambala had two he says. “I’d never seen snow in says. Dr. Alba says she has also felt patient care and research.” welcomed by the team there,” he says. “I am still connected all Toronto family.”

12 Peter Munk Cardiac Centre Winter 2018 13

DM182487_Pg01-51_PMCC_FALL_2017.indd 12 2017-10-06 11:06 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 13 2017-10-06 11:06 AM A steady stream of innovations point to the day when electronic pacemakers may be obsolete

Development and advancements on the heart- regulating apparatus over the past decade have been phenomenal

By Chris Atchison

DR. GORDON CHONG MAY batteries need replacing. HAVE DEDICATED HIS CAREER Dr. Chong has a unique TO FIXING TEETH, but his perspective on the evolution golden years have included an of the heart-regulating unexpected education in cardiac apparatus, thanks to his medical care – specifically, his own. background. A retired dentist, Dr. Chong “I spent two years [studying] has been the recipient of at the Hospital for Sick Children four pacemakers since being when I graduated and have diagnosed with congestive heart been following (pacemaker failure in 2011. His pacemaker development) for the past few has since been fitted with a years…and in the last decade, defibrillator to keep his heart the amount of knowledge and functioning in the event of a technology, and bringing together major cardiac incident. of biometrics and biology, has “It seems to be working well, been phenomenal,” the 73-year- but the condition I have is still old says. deteriorating,” says Dr. Chong. Indeed, the devices have come a “I’m being assessed for a heart long way since the invention of an transplant or a mechanical device external, toaster-sized pacemaker that will get me over the hump for in 1950 by Canadian engineer a while.” John Hopps, in conjunction with Dr. Chong, a patient of the Peter researchers from the University of Munk Cardiac Centre (PMCC), Toronto. is one of more than 10,000 Despite its many shortcomings Canadians who receive electronic – the device required an AC pacemakers each year and one of power source, creating obvious more than 120,000 Canadians mobility challenges for patients – currently living with the life- Hopps’s pacemaker was regarded saving technology. as a drastic improvement over The tiny devices treat previous rudimentary devices. arrhythmias – abnormal heart That was until a team in rhythms – and help the heart Minnesota developed a battery- beat at a steady, normal pace. powered, belt-worn pacemaker Pacemakers average about a later that same decade. 01 seven-year lifespan before their Fully implantable devices

14 Peter Munk Cardiac Centre Winter 2018 15

DM182487_Pg01-51_PMCC_FALL_2017.indd 14 2017-10-06 11:07 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 15 2017-10-06 11:07 AM became available in the 1960s. regions causing atrial fibrillation outside the pulmonary veins that into rat hearts and assumed a Continued improvements have are not apparent with current doctors can’t see or treat. biological pacemaker function, UHN IS COMMITTED reduced the pacemaker’s size, technology. “That brings in the notion of exactly as planned. while improving battery life This is where University Health finding and ablating electrical “The groundbreaking TO IMPROVING and overall effectiveness. The Network’s Thomas I. (Toby) Hull drivers that can be outside advancement could lead to the development of specialized Centre of Excellence in Heart pulmonary veins,” Dr. Chauhan development of a biological models, such as biventricular Rhythm Disease program aims to says. pacemaker for humans that PATIENT SAFETY pacemakers, has further improved be innovative. But without an effective tool to would offer immediate benefits patient survival rates and quality Consider the work of Dr. Vijay do exactly that, Dr. Chauhan and over current electronic pacemaker of life. Chauhan, a cardiologist at the his team developed a mapping devices, which have limited It’s not only the direct PMCC who is developing new technology which systematically battery lives and are unable to technological advancements technology to localize atrial analyzes the atrial fibrillation adapt to changes in heart sizes in pacemaker design that have fibrillation electrical drivers electrical signals from hundreds in pediatric patients. The team’s SO IS MEDTRONIC researchers and clinicians excited, in order to improve catheter of regions in the heart. With long-term goal is to produce the but also innovations in related ablation for patients with atrial a study currently underway, human heart cells that make up treatments and diagnostic fibrillation. researchers should know in a year the organ’s chambers, including procedures that could one day Dr. Chauhan and his team have whether the new treatment does, the ventricles and atria. The goal make electronic pacemakers set out to find what he calls “the indeed, improve catheter ablation is to use these ventricular cells to virtually obsolete. flashing beacon in the heart” success rates. create new muscle in the hearts One of the most common that may sometimes trigger and Other researchers, including of patients who have experienced heart rhythm disorders is sustain the condition. Dr. Gordon Keller, Director of a heart attack. The whole idea of atrial fibrillation, which affects To curb atrial fibrillation, the University Health Network’s using cells we make in a lab to millions of people worldwide. doctors often begin with drug McEwen Centre for Regenerative treat patients may be closer than The condition causes disabling treatments, and if unsuccessful, Medicine in Toronto, are using we thought,” Dr. Keller says. symptoms of palpitations and an they will then perform a catheter trailblazing biological innovations increased risk of heart failure, ablation around the pulmonary to improve heart health and stroke and death. An important veins to normalize the patient’s potentially mitigate the use of 01 Drs. Vijay Chauhan and Andrew Ha, cardiologists at treatment option for patients heart rhythm. pacemakers. the PMCC, and their team who cannot be managed with But catheter ablation has In 2016, Dr. Keller and his looking for “the flashing medications is a heart procedure only a 50 per cent success rate, team announced that they beacon in the heart” that may known as catheter ablation, particularly in patients whose had produced sinoatrial node trigger atrial fibrillation. where regions of the heart muscle atrial fibrillation persists all the pacemaker cells – which causing atrial fibrillation are time, due largely to the fact that regulate the heart’s rhythm with 02 Dr. Gordon Chong, a burned away. However, this atrial fibrillation in these patients electrical impulses – from human retired dentist and patient at procedure may not work well often stems from abnormal pluripotent stem cells. The the PMCC, has had multiple in many patients because the electrical areas in the heart pacemaker cells were injected pacemakers since 2011.

02 THAT IS WHY WE ARE DESIGNING MORE OF OUR DEVICES FOR SAFE USE IN AN MRI. After age 65, the likelihood of needing an MRI doubles. This is also the age group most likely to need a pacemaker.1 If you, your loved one, or your patient has a pacemaker, they have a 50-75% chance of needing an MRI over the lifetime of their device.2 In 2011, Medtronic launched the first pacemaker in Canada that was safe to use in an MRI.3 We didn’t stop there. We did the same with our: • Neurostimulator for Parkinson’s in 2013, • Insertable cardiac monitor for unexplained fainting or stroke in 2014, • Implantable cardioverter defibrillator (ICD) for heart failure in 2015, • Spinal cord stimulator (SCS) for chronic pain4 in 2016, and • Cardiac resynchronyzation therapy-defibrillator (CRT-D) for heart failure in 2017. Now, more Canadians with these medical devices can safely access an MRI. LEARN MORE AT MEDTRONIC.CA/MRI

1. RON KALEN and MARSHALL S. STANTON, Current Clinical Issues for MRI Scanning or Pacemaker and Defibrillator Patients (PACE 2005; 28:326-328). 2. Medical Imaging in Canada: http://www.cihi.ca/CIHI-ext-portal/internet/EN/TabbedCotent/types+of+care/specialized+services/medical+imaging/cihi010642. 3. Consult the conditions of use with your physician. 4. Chronic, intractable back and/or leg pain. © 2017 Medtronic. All rights reserved. Medtronic logo and Further, Together are trademarks of Medtronic. 16 Peter Munk Cardiac Centre

DM182487_Pg01-51_PMCC_FALL_2017.indd 16 2017-10-06 11:07 AM DM182487_Pg17_PMCC_FALL_2017.indd 17 17-10-06 1:25 PM and scientists are on the verge • the use of donor hearts that heart disease,” Dr. Badiwala leading-edge biotechnology such of breakthroughs that promise were previously considered too explains. as gene or stem cell therapy are to increase the success of heart damaged to transplant, making At the same time, “there are developed. Paving the way transplants and which may vastly “We’re probably transplants available to many hearts out there that we know This goes beyond fixing expand the number of patients more people; have only temporary damage, the temporary damage that who can receive the life-saving taking only up • the possibility of stem cell and even though the donor is sometimes shows up in donors’ to truly mend a treatment. treatment to repair damaged brain-dead, the heart has the hearts. The first successful heart to 35 per cent of hearts; and potential to recover,” he says. “We may be able to repair hearts transplant in Toronto took place the hearts from • taking a patient’s own heart Understandably, grieving that right now are not useable,” broken (donor) on November 17, 1968, at St. and putting it “on the hoist” families want a donor’s heart to Dr. Badiwala says. Michael’s Hospital, performed by donors. The rest – removing it temporarily for be used quickly to save someone, The team is also about to Dr. Clare Baker on Charles Perrin are turned down, repairs and then reinstalling it, so Dr. Badiwala and his team are begin clinical trials with DCD Johnston, who lived until 1975. rather than replacing it with a working on technology that can – or “donation after circulatory heart in the future It took place after two earlier sometimes because donor’s heart. repair temporary heart damage death” – hearts. Unlike hearts transplants in Toronto in which the donors are “In the first 30 years, nothing as fast as possible. that come from donors who are Anticipated breakthroughs by Peter Munk Cardiac Centre doctors patients died within a week of has really changed in terms of “We’re testing the machine in brain-dead, DCD hearts have surgery, as well as less than a year really old or have the surgery itself – until recently,” the lab now. We hope that later been considered unreliable for and scientists could lead to more donor hearts, fewer rejections, after the world’s first heart-to- says Dr. Mitesh Badiwala, a this year, we’ll be able to use transplants because they stopped advanced stem cell treatments and repairs to a patient’s own heart heart transplant was performed heart disease.” cardiac surgeon at the PMCC. human hearts that have been beating when the donor died. in South Africa by Dr. Christian “We’d take a donor’s heart, flush discarded as too damaged for Hospitals in Britain and Barnard. Dr. Mitesh Badiwala, it and package it in a cooler full transplants and see how many Australia are now using DCD Cardiac Surgeon In the next 30 years, the of ice.” Donors are always those we can bring back,” Dr. Badiwala hearts. By David Israelson possibilities for innovation range who have been declared brain- says. “They’ve done this in those from incremental improvements dead, with no hope of recovery. “At some point, when we’re two centres nearly 50 times. in technology and medication to Brain death is declared when it confident that the hearts are My team and I visited the Star Trek-like procedures that 01 Dr. Mitesh Badiwala and is clearly irreversible, and it is a working well, we’ll be able to take facility in Papworth, England THREE DECADES AFTER THE here long enough to have worked part of the University Health are so stunning they’re barely his team are working on a legally accepted concept of death them off the machine and use (near Cambridge), and we FIRST SUCCESSFUL HEART on 500,” says Dr. Heather Ross, Network. imaginable. host of new technologies, in virtually every country in the them for transplants.” were impressed. They were TRANSPLANT WAS ACHIEVED world-renowned cardiologist and “It’s still a remarkable Dr. Ross says the breakthroughs some which will be able to world. Perhaps an even more exciting able to increase their volume of IN TORONTO, the medical Director of the Ted Rogers and achievement every time it and discoveries that medical repair heart damage as fast Still, even when a donor has aspect of this research into transplantation by more than 50 mysteries keep unravelling, and Family Centre of Excellence in happens,” Dr. Ross says. teams are working on now as possible. been declared brain-dead, correcting damage is that it may per cent,” Dr. Badiwala says. the miracles keep multiplying. Heart Function and the Cardiac Thanks to new research and include: doctors can’t use hearts that are make it literally possible to fix a “We hope to decrease the 02 Dr. Heather Ross, “We have done more than 700 Transplant Program at the Peter technology, it’s getting more • new medications that lower the damaged. So, many people who broken heart. incidence of patients who die Director of the Ted transplants, and I have been Munk Cardiac Centre (PMCC), remarkable all the time. Doctors risk of cellular rejection; Rogers and Family Centre need transplants are placed on “It gives us an opportunity to while they’re on waiting lists.” of Excellence in Heart waiting lists. potentially repair hearts, with Donors’ and families’ wishes Function, has worked on “We’re probably taking only new strategies that are being must be respected, including up to 35 per cent of the hearts used in other labs,” Dr. Badiwala when it is appropriate to 01 500 of the more than 700 heart transplants done to from donors. The rest are turned says. New medications can be withdraw life support for a date at the Toronto General down, sometimes because the used experimentally without patient who will not recover. The Hospital and the PMCC. donors are really old or have putting patients at risk, as legal definition of a circulatory death in Canada is when a person’s heart has stopped beating for five minutes, Dr. 02 Badiwala notes. Which leads to a dream for the future. “We can dream of the device we’re working on to repair hearts becoming a device not just to repair hearts for transplant, but [also] to repair your own heart,” Dr. Badiwala says. “Take it out, put it on the machine and transplant it right back into you.” This is not as far-fetched as it sounds. He points out that patients on waiting lists already survive for short periods, even months sometimes, with mechanical heart devices. Maybe they can do so while their own hearts are on the hoist. Yet as promising as the future may be, the present at the PMCC is pretty amazing, too, Dr. Ross says. “I’ve been working in this area for 23 years, and every time we do a transplant it seems like the first time, in terms of miraculous and life-saving potential.”

18 Peter Munk Cardiac Centre Winter 2018 19

DM182487_Pg01-51_PMCC_FALL_2017.indd 18 2017-10-06 11:27 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 19 2017-10-06 11:27 AM patients’ clinical data, including subsequently developed into MRI and other imaging. a drug called Herceptin – that “This is one of the largest targets HER2-positive breast biobanks of its kind in Canada, cancer cell receptors. “Our goal is to representing a full gamut of “The biobank is useful for create a large cardiovascular diseases,” says Dr. those of us who do research on Billia, who notes that all samples biological markers that we can consortium of and data are scrubbed of any measure from blood serum,” cardiovascular details that could identify their says Dr. Michael Gollob, Chair source. of the Centre of Excellence in researchers in the The PMCC Biobank, enabled Molecular Medicine, a research GTA who would through the efforts of the program within the PMCC that’s Ted Rogers Centre for Heart advancing personalized patient have access to Research, holds out the promise care by combining traditional this incredible of more precise, personalized clinical information with medicine. With its large – and genetic, molecular, cellular and resource.” still-growing – collection of physiological data. “Having the Dr. Richard Weisel, samples and data, the biobank blood or tissue samples from the Cardiovascular Surgeon, PMCC, gives scientists access to research biobank also enables us to extract Senior Scientist, Toronto General material with much greater DNA from those samples and Research Institute depth and breadth than what conduct DNA-based research.” they would find in their own For patients, this translates laboratory biobanks. into a future where therapies are The value of biobanks to fine-tuned to match each person’s cases involving patients with researchers is underlined by genetic makeup. Dr. Billia, for dilated aortas, which would numerous success stories in instance, is leading a study that normally be removed and various fields. In cancer research, uses blood from patients with replaced once the affected blood the ability to screen banked tissue hypertrophic cardiomyopathy – vessels have grown to a radius of samples led to the discovery an inherited heart condition – to at least five centimetres. of an antibody – which was create laboratory models of the “But some surgeons wondered if disease that are then used to test that’s the right cut-off in deciding a range of treatments. whether that blood vessel should 01 Dr. Phyllis Billia, far left, “This is a genetic condition with be removed or not, mostly Dr. Michael Gollob and a 50 per cent chance of getting because we don’t understand the Dr. Richard Weisel spearhead passed on to your children, and mechanisms in which the dilation work at the Biobank, which stores more than 25,000 blood each child could potentially have occurs,” says Dr. Weisel, who is and tissue samples. different manifestations of the one of the scientists leading the condition. One could have a long PMCC Biobank. “So we took 02 Dr. Billia says the goal of life expectancy, while another samples from the biobank and the Biobank is to discover new could just die suddenly from were able to look at patients who 01 treatments for various types of cardiac arrest,” explains Dr. Billia. seem to have progression of the cardiovascular disease. “By using a patient’s blood sample disease, versus those who did not.” to model the disease in the lab, This large-scale comparison gave we can test a library of drugs to doctors a better understanding of THERE ARE OVER 163,000 goal ultimately is to use this see how the patient is likely to the disease and revealed certain 02 OUTPATIENT VISITS TO THE information to discover potential respond to each drug, allowing genetic abnormalities associated PETER MUNK CARDIAC new treatments for the various us to tailor treatment for each with dilated aortas – new CENTRE (PMCC) each year, types of cardiovascular disease.” individual.” knowledge that has since led to where cardiovascular diseases Housed in a secured facility Dr. Gollob says the PMCC new therapies for the condition, Banking that range from arrhythmia to at the PMCC, the biobank is a Biobank will also allow he says. heart failure are treated. Over massive repository containing researchers to genetically The PMCC Biobank continues the last three years, a growing more than 25,000 blood and model the different types of to be a work in progress. A on the number of these patients have tissue samples – a significant cardiovascular disease in various key goal, says Dr. Weisel, is to also become contributors to the increase from the roughly 2,000 ways. For example: by identifying combine this project with other centre’s biobank – an ambitious samples collected two years ago. a specific DNA alteration of a cardiovascular biobanks in future research infrastructure project The recent acceleration of blood particular heart cell leading to Toronto and make the aggregate that’s opening the way to a deeper and tissue sample collection can disease, scientists may be able to samples and data available to all understanding of cardiovascular be attributed to the efforts of intervene on the pathway of the researchers in the city. A massive biospecimen and data disease and the treatments that the PMCC’s Ted Rogers Centre disease. “Our goal is to create a large repository at the Peter Munk work best for each patient. for Heart Research site, where “From genetic discovery, we consortium of cardiovascular “What we have at the PMCC is biobanking is an essential pillar can then consider or innovate researchers in the Greater Cardiac Centre holds the promise a unique opportunity to examine to many of the research activities. potential treatments targeting Toronto Area who would have of more precise, personalized specimens from thousands of To build the biobank, the PMCC the disease-causing gene and its access to this incredible resource,” medicine patients [in order] to look for asks patients who go through protein,” says Dr. Gollob. he says. “We also hope to expand biological markers and novel procedures that require the Dr. Richard Weisel, a our capabilities to the extent pathways of cardiovascular collection or removal of biological cardiovascular surgeon at the where we’ll have samples from disease,” explains Dr. Phyllis specimen – such as blood tests or PMCC and Co-director of the all patients at the PMCC – By Marjo Johne Billia, a scientist and Co-director surgery – for permission to store Biobank, says the biobank has something that’s done as routine of the Peter Munk Cardiac Centre their tissue or blood. already had an impact in cardiac in some places in the United Cardiovascular Biobank. “The These samples are then linked to surgery. As an example, he cites States and Europe.”

20 Peter Munk Cardiac Centre Winter 2018 21

DM182487_Pg01-50_PMCC_FALL_2017.indd 20 2017-10-13 9:41 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 21 2017-10-13 9:41 AM Over the next three years, anymore.” the damage worsened to the Now that funding has been The look and function of Left point where, in 2010, her heart extended to non-transplant Ventricular Assist Devices (LVADs) essentially stopped working on patients, the number of LVADs its own. Doctors had to implant installed should triple – from have evolved over the years and are a left ventricular assist device 30 to 90. That number could now being combined with other (LVAD) – a battery-powered grow even more, as technology mechanical heart that pumps continues to improve. It may treatments, blood through the body. not be long before Dr. Rao is such as stem cell While Ms. Lorde had to plug installing LVAD devices that it in every night, and she had charge without needing to be technology, to to be mindful of the power plugged in. “We’ll get to the point restore function cord sticking out of her chest, it where devices are completely helped improve her life. “I had to implantable, and they charge to a patient’s own be careful, but I got around to do like a watch battery,” he says. “It heart: a lot of things, like my cooking won’t impact life in any way, and and washing,” she says. “I didn’t you won’t have to worry about feel sorry for myself.” your heart failing.” Ms. Lorde received her mechanical heart (called a MAKING BAD HEARTS 2001 Duraheart) at the Peter Munk GOOD AGAIN Heartmate I Cardiac Centre (PMCC), which, While the PMCC’s mechanical (1,225 g) over the last 16 years, has heart program is mostly focused developed a robust mechanical on implanting LVADs, it’s also circulatory support program – it doing groundbreaking research installed its 200th LVAD in late around stem cell technology, says 2016. Dr. Terrence Yau, cardiovascular In 2001, Dr. Vivek Rao, surgeon and Angelo & Lorenza Division Head of Cardiovascular DeGasperis Chair in Cardiovas- 2004 Surgery at PMCC and the Peter cular Surgery Research. He’s Novacore Munk Cardiac Centre Chair in currently trying to see if stem Advanced Cardiac Therapeutics, cells injected into the heart can (550 g) launched the LVAD program help the patient’s heart work on in Toronto after working under its own again. Dr. Mehmet Oz at Columbia Dr. Yau is taking patients with University, Department of LVADs, putting stem cells into Surgery, in New York, which their heart and then turning has one of the world’s largest down the LVADs to reduce their mechanical heart programs. pumping function. Normally, Marva Lorde relied on Those first few years were if an LVAD is turned off or a left ventricular assist challenging, as the program was down, the patient’s heart almost device (LVAD) for two exclusively funded by donors, instantly fails. However, in the 2006 Heartmate II years before receiving which meant only about five to first phase of testing, Dr. Yau a heart transplant. 10 devices a year were paid for. found that half of the patients (450 g) In 2012, though, the government who received stem cell injections began covering LVADs for use in could tolerate a reduction in the WHEN MARVA LORDE WENT patients on the heart transplant LVAD’s power, compared to only TO BED ON THE NIGHT OF list, and the number of people 20 per cent of those patients who OCTOBER 25, 2007, nothing receiving the device rose. Now, did not receive stem cells. Mechanical hearts are seemed out of the ordinary. The Dr. Rao and his team install The second phase of the trials 2010 former bank employee had been about 30 annually. are now underway, which will Duraheart enjoying a life of leisure after see even more stem cells injected (540 g) buying time for patients working for 34 years, and she MORE LVADS NEEDED into LVAD patient hearts. The was looking forward to going to However, it’s still not enough, goal? To get people’s hearts her regular workout class in the says Dr. Rao. Most people with pumping again. “We want to be and groundbreaking morning. At some point during heart failure aren’t candidates able to take the LVAD out and the night, though, a feeling of for heart transplants. They leave the patient with their own indigestion came over her, and might have a history of cancer or heart,” says Dr. Yau. “There’s soon after the clamminess and lung problems that make them nothing better than having your 2010 research vomiting began. ineligible for a new transplant. own well-functioning heart.” Heartware Despite feeling ill, she drove LVADs, though, can help them Ms. Lorde knows that better (160 g) Combined with stem cell technology, herself to the hospital, where she live long and fulfilling lives. than most. In 2012, she received learned she had experienced a “Patients with heart failure who a heart transplant, which meant a patient’s own heart can start pumping again massive heart attack and had to are not transplant candidates are she no longer needed the LVAD. stay in the Coronary Intensive given a death sentence,” says Dr. Now she can do everything she Care Unit for the next 10 days. Rao. “They have one or two years used to do, including going to By Bryan Borzykowski “There was no pain, but on the to live, and it’s not a great life. exercise classes. “I’ve never felt 2014 inside damage was happening,” But those who get these devices better,” says Ms. Lorde. “And that Heartmate III she says. “I thought it was just a do live active lives. They’re LVAD really helped me as I was (200 g) virus.” not restricted by heart failure waiting for a transplant.”

22 Peter Munk Cardiac Centre Winter 2018 23

DM182487_Pg01-50_PMCC_FALL_2017.indd 22 2017-10-13 9:41 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 23 2017-10-13 9:41 AM Imaging…with WHY USE A PET-MRI? • It combines the spectacular structural imaging of an MRI heart and with the ability to detect physiological changes in blood innovation flow, viability and function. • Images are taken simultaneously – quicker than A cutting-edge PET-MRI machine has using two separate imaging enabled doctors to find new, less-invasive machines. ways to improve the lives of patients and • A small amount of ionizing conduct new research radiation is a real boon, particularly for pediatric patients who must be monitored their entire lives. • By Kira Vermond

ANYONE WHO HAS EVER SLID THROUGH THE TUNNEL OF A MAGNETIC RESONANCE IMAGING (MRI) machine likely remembers its raucous whirring and knocking, not to mention the squeeze of a snug 70-centimetre- tensile strength. There, she can wide bore. determine if the aortic wall But for some patients was, in fact, weak and prone to undergoing procedures at the rupture. Peter Munk Cardiac Centre It’s early days for Dr. (PMCC), the time spent in the Ouzounian’s research, but she life-saving imaging machine will hopes the PET-MRI results will result in something even more – give surgeons a new, less-invasive Positron Emission Tomography diagnostic tool that will tell them (PET) images. which aortas are vulnerable. Back in April 2016, the centre “If we do find parameters acquired and installed one of only that are predictive, we could about 160 PET-MRI combination tailor our therapies more to the machines in the world, giving specific individual,” she says. “The cardiology researchers access PET-MRI gives us a much more to the cutting-edge, hybrid in-depth look at somebody’s aorta technology. While MR uses and allows more personalized strong magnetic fields to generate decision making.” Dr. Maral Ouzounian, hyper-detailed images of the imaging, so you don’t have a delay increased delivery of energy to AVOIDING take a wait-and-see approach. Ouzounian is looking at novel Considering the risk of death opposite, Dr. Patrick Veit- body’s organs, a PET scan offers between one image and another.” the small blood vessels in the THE WORST Some aneurysms are stable ways that imaging can help is only less than 1 per cent for Haibach, left above, and information about metabolic Now, the machine is being brain. “The brain gets more of a Meanwhile, Dr. Maral and are unlikely to rupture. But predict which patients have elective surgery, it’s no wonder Dr. Michael Domanski are changes happening in organs or used to conduct new research, pounding,” says Dr. Domanski. Ouzounian, a cardiac surgeon part of the team-based others are far more dangerous. vulnerable aortas. Not only does Dr. Ouzounian is looking for tissues. The images are generated determining everything from “So the question is: ‘Can we link who specializes in aortic disease approach at the PMCC The problem is, it’s not easy to tell it allow her team to examine ways to avoid risky emergency simultaneously. how heart and brain health this pounding to Alzheimer’s?’” at the PMCC, has a grand that works to maximize one from the other, so physicians inflammation of the aortic wall, surgeries. It’s the best of both worlds, are connected to pinpointing Dr. Domanski’s team will be vision of her own. After moving innovation using the PET- depend on their size as a guide. In which can’t be completed with She’s pleased she’s been able to explains Dr. Patrick Veit- dangerous aortic aneurysms. using a combination of PET-MRI to Toronto from Houston in MRI machine. the part of the aorta that is close a CT scan or an ultrasound, conduct her potentially life- Haibach, Clinical Director of the and hemodynamics – measuring 2014, she has performed many to the heart (root or ascending), but she can also look at the saving research at the PMCC, PET-MRI, Joint Department of HEART AND pressure and flow – to examine surgeries on patients with aneurysms are repaired if they are biomechanical properties of the where she works daily alongside Medical Imaging (JDMI), and a BRAIN LINK the effect of arterial stiffness on aneurysms or dissections in their larger than 5.5 centimetres. wall. How stiff or compliant is vascular surgeons, interventional German radiologist and nuclear Take the work being done by damage to the brain. aorta. “If you tear your aorta at home, Yet size can be misleading, says it? How is the wall handling the radiologists, cardiology partners medicine physician who came to Dr. Michael Domanski, Division If his team can correlate The aorta is the main artery most of the time you don’t even Dr. Ouzounian. Some will rupture pressure? and even geneticists. Canada from Switzerland in April Head, Cardiology. He’s studying pressures and flows with that carries blood away from the make it to the hospital; it’s a fatal or dissect when they’re smaller, Once patients have their PET- “I really like the team-based 2017. the link between aging arteries changes in the brain, they will heart to the rest of the body. If event,” she cautions. while others remain stable even MRI scan, they’re wheeled to nature of the work at [the] Peter “A PET-MRI should give you and neurological disorders such have taken a step toward better an aneurysm forms there – the Most people don’t even realize as they hit the six-centimetre surgery, where Dr. Ouzounian Munk [Cardiac Centre] and complementary information as Alzheimer’s, which causes understanding the link between artery wall weakens, so that it they’re living with an aneurysm threshold. removes the aorta and replaces it the opportunity to do high-end about the disease,” he says. memory loss and cognitive blood vessel changes and loss of balloons out – it can quickly until it shows up on an unrelated But her new research could with graft material. The patient’s surgery and research,” she says. “At least for certain research decline. intellectual function. become a serious, life-threatening echocardiogram or CT scan. change when and how surgeons aortic tissue is then taken to the “My goal was to be an academic questions, it’s very important As people age, their arteries “That’s the grand scheme,” he medical emergency if the Then the surgeon has a decision decide to operate. By using the lab, where it is examined under aortic surgeon – and this is the to have real-time simultaneous stiffen, which exposes them to says. aneurysm tears and bursts. to make: operate to remove it or hybrid PET-MRI machine, Dr. the microscope and tested for best place to do it.”

24 Peter Munk Cardiac Centre Winter 2018 25

DM182487_Pg01-51_PMCC_FALL_2017.indd 24 2017-10-06 11:28 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 25 2017-10-06 11:28 AM or the app tells them to contact us to discuss the problem.” Virtual For the clinicians, this advanced technology marries the vital components of self-management care and education in cardiac health care. Dr. Jane MacIver, nursing leaps professor in cardiovascular research for the Ted Rogers Centre for Heart Research, says it’s about the teachable forward moments this type of technology provides. A large part of cardiac Advanced technology helps health is providing patients with information about how lifestyle doctors empower patients’ choices affect one’s heart health. self-care Her work is focused around CardioMEMS, a system designed in the U.S. and only used on two patients in Canada By Daina Lawrence so far, as approval is pending. CardioMems is a heart monitor that is inserted into a person’s MORE THAN ONE MILLION lung artery and gives real-time CANADIANS CURRENTLY LIVE blood pressure readings back to WITH HEART FAILURE, and the clinician, allowing for more 50,000 new cases are diagnosed immediate lifestyle or medication each year. These numbers cost adjustments. the Canadian health-care system For instance, if a person has more than $3-billion annually, been neglecting a healthy diet according to the Heart Research and reaching for sodium-rich Institute (Canada). snacks, CardioMEMS will “We have an epidemic of heart pick up on the effects. “For the disease, more specifically heart 02 patient, it allows them to see how failure. And we can’t keep doing the changes they make in their big-box medicine,” says Dr. life can affect their reading,” says Heather Ross, Director of the Dr. MacIver. Ted Rogers and Family Centre 01 Dr. Heather Ross notes “It’s more impactful than that the epidemic of heart of Excellence in Heart Function saying, ‘Don’t take any more disease in Canada means and a cardiologist at the Peter than 1,500 milligrams of salt. It 03 new monitoring methods, Munk Cardiac Centre (PMCC). 01 such as CardioMEMS, doesn’t mean anything to them, While medical advances in must be developed. but they can see [a salty] buffet Canada are helping to treat those is bad because it causes weight with heart disease, there are 02 Nurse Practioner gain.” new systems that put the onus, But this advanced technology have an effect on heart health. pressure cuff and scale that are Meredith Linghorne As part of Dr. MacIver’s as well as the power to drive an helps health-care providers offer “If you think about obesity, digitally linked to a Bluetooth- shows a patient how research, her team will individual’s health, back in the timely, optimal and efficient diabetes, physical inactivity – enabled device. to use CardioMEMS, measure the out-of-pocket hands of the patient. patient care with real-time all things that are risk factors Meredith Linghorne is a Nurse a mobile application expenses associated with the Innovations in heart failure patient data in the hopes of for heart failure – if we can Practitioner-Adult at the PMCC, system that allows real- CardioMEMS device. It’s true research are spearheaded at reducing the strain on Canada’s engage patients, we should be and she is on the receiving end of time measurement of a there is no direct cost to the the University Health Network health-care system. able to dramatically reduce the Medly’s patient data. patient’s fluid status. The patient for the device itself, but (UHN) site of the Ted Rogers “Virtual care has been a term incidence or prevalence of heart “Medly allows us to see key PMCC was the first health- Dr. MacIver explains there can Centre for Heart Research, that has been thrown around, disease, and therefore, heart clinical data, such as changes in care centre in Canada to be extra costs such as increasing which is an integral program of but I think this is virtual care on failure,” explains Dr. Ross. weight and patient’s symptoms, implant a CardioMEMS the bandwidth on an individual’s device. the PMCC. Here, Dr. Ross and steroids,” says Dr. Ross. “What And while some of the inner without having them come into Internet to accommodate her team are using smartphone we have is a set of virtual tools workings of these systems the clinic,” says Ms. Linghorne. the device and its Bluetooth 03 Medly, the mobile apps, digital platforms and even to enhance self-care and to are staggeringly complex, the She says that patients are asked application system readings. There will also be home a Bluetooth-enabled monitor enlist patients in their own care, equipment the patients use at to monitor their blood pressure, designed at UHN, consists visits to CardioMEMS patients to implanted into a patient’s lungs because patients are the largest home is fairly simple. heart rate, weight and simple of a blood pressure cuff study ease of use. to help manage symptoms and work force in health care.” Patients don’t need to come symptoms on a daily basis – and scale that are digitally “I think it’s one thing if the triggers of heart failure, educate The main objective is to create into a clinic for a weigh-in. They something that would have been linked to a Bluetooth- technology makes sense to a patients and limit hospital trips. an easy-to-use, patient self-care can simply stand on a scale impossible before without daily enabled device. clinician, but if we find out it is Cardiovascular disease is one and treatment program that is hooked up to an app on their trips to a clinic or a hospital. really ineffective for the patient, of this country’s largest killers. both mobile and electronically smartphone, and the details are “With this information, I then are they really going to use Someone in Canada dies every based. Patients don’t need to go sent digitally to a team of health- know when they’re getting into it,” says Dr. MacIver. “It’s taking seven minutes from a heart to the clinic as often, and they care providers. At least this is the trouble. And this particular it one step further and saying, attack or stroke, according to the can track symptoms and progress thinking behind Medly, a mobile app is designed so they will get ‘Yes, we have this technology, Heart and Stroke Foundation of at the touch of a button, showing application system designed at immediate feedback from us 03 but let’s look at how it’s actually Canada. them how lifestyle choices can UHN that consists of a blood after taking their measurements, picked up in the real world.’”

26 Peter Munk Cardiac Centre Winter 2018 27

DM182487_Pg26-27_PMCC_FALL_2017.indd 26 2017-10-10 12:56 PM DM182487_Pg26-27_PMCC_FALL_2017.indd 27 2017-10-10 12:56 PM NAZMOON GRIFFITH concerned about the details of the POINTS TO HER CHEST AND procedures, the months of days Solving the ABDOMEN TO ILLUSTRATE and nights in the Cardiovascular THE SURGERIES at the Peter Intensive Care Unit (CVICU), the Munk Cardiac Centre (PMCC) blood transfusions, the postop complex that repaired her aorta, the stroke, dialysis and time on the main artery that carries blood ventilator. throughout the body. Her 31-year-old great-niece, puzzle of Perched on the seat of her Melissa Rahaman, a member walker in her Toronto, Ont., of the Canadian military, talked studio apartment, she traces lines with the doctors and explained vertically and diagonally across the procedures and risks to her. aortic disease the front of her body. “My aunt doesn’t have the most “They cut here,” she says, as if education,” says Ms. Rahaman. A team approach allows doctors to offer solutions, unzipping a zipper, “and here. “She didn’t really understand And here.” what was wrong with her. I had and quality care, to patients like Nazmoon Griffith Mrs. Griffith adds: “Then again to keep track of everything. I did here. And here.” a lot of my own research.” The 73-year-old native of She also found the surgical By Judy Gerstel Guyana, who came to Canada in team leader, Dr. Thomas Lindsay, 1968, says she doesn’t remember Division Head of Vascular much these days. And she wasn’t Surgery and the R. Fraser Elliot

Winter 2018 29

DM182487_Pg01-50_PMCC_FALL_2017.indd 29 2017-10-13 9:42 AM DM182487_Pg28_PMCC_FALL_2017.indd 28 17-10-06 1:29 PM Chair in Vascular Surgery, through which blood flowed, with to be “super approachable. I the weaker one transporting the didn’t feel nervous about asking blood. “The only way to fix an enlarged aortic artery a few decades ago was to do a him questions. He was very When aortic dissection occurs reassuring, and he was really on an emergency basis, as major open repair. But a way was invented to do it through inside the blood involved, checking on her every a sudden tear followed by a day.” rupture, death usually follows vessel, under X-ray control with a custom-made, flexible synthetic tube that Dr. Lindsay, in turn, appreciated within hours or days. Acute aortic Ms. Rahaman. dissection was the cause of death can go around corners.” “Sometimes the patient is for actors John Ritter and Alan Dr. Thomas Lindsay, Division Head of Vascular Surgery blissfully unaware,” he says. “Her Thicke. niece was invaluable. When With extensive aneurysms and problems arose, we made sure to chronic dissection, Mrs. Griffith talk to the niece, as well.” required complex and innovative Even the fact that the case surgery to save her life. with an open branch “hanging explains Dr. Lindsay. innovating, figuring out how was one of the first of its kind “Only a handful of these in the breeze,” she says. That’s “But a way was invented to to do it better. And I work with DID YOU KNOW… in Canada and involved a large, operations are done to treat the “elephant trunk” to which do it through inside the blood colleagues who think the same highly skilled and creative team chronic dissection,” explains Dr. the second surgical team would vessel, under X-ray control, with way. That’s what’s so enjoyable meeting and planning six months Kong Teng (KT) Tan, Division attach another tube, to replace a custom-made, flexible synthetic about working at the PMCC.” • Aortic disease is often in advance of the first operation Head, Interventional Radiology. the thoracic and abdominal tube that can go around corners.” Dr. Lindsay explains: “The field hereditary. If someone has a was of no great relevance to Mrs. “She was the first case in aorta. A copy of Mrs. Griffith’s CT scan is evolving, and we’re coming thoracic aneurysm – a bulging Griffith. Canada. Stents are not currently For the complex open chest was sent to the manufacturer up with creative solutions to get of the aorta in the chest area What does impress her, though, designed for this, so we had to procedure, “you need the heart of the device, and a plan for these patients safely through (thorax) – there’s a 20 per cent is how she was cared for. think outside the box. Everything lung machine, because the arch construction of the made-to- everything they need. If you have chance that it is due to genetic “They treated me so well,” she had to be perfectly planned from involves all the blood vessels to measure Dacron mesh and metal all the tools at hand, you can offer factors and that other members recalls. “Everybody knows me, step one.” the brain, the upper body and the tube was sent back to Dr. Lindsay a personalized approach to fixing of the family also have or are almost like family.” He adds, “You think about it arms, so you need to turn off or and Dr. Tan. the problem.” at risk of developing a similar She’s also impressed with the a lot. It makes a big difference reduce the blood flow to the brain “If we agree with the plan we He says that “the postop care aneurysm, explains Dr. Maral result. where you cut. You get one shot for a certain amount of time,” sign it, and six to eight weeks from intensivists and ICU nurses Ouzounian, a cardiac and aortic “I thank God I’m alive,” she says. to get it right. You get it wrong, clarifies Dr. Ouzounian. later we receive the device, which is also critical. “These patients surgeon. Young patients with “People who know me say, ‘You’re it’s almost impossible to fix. “If I just turned the blood flow we put in through the patient’s need very specialized nursing; a thoracic aneurysm or those looking good.’” Errors in the procedure cannot to the brain off at normal body arteries in a high-tech operating they need spinal drains.” with a family history may be Mrs. Griffith’s aorta was so be resolved. In my mind, I went temperature, I’d only have three room with radiology equipment,” As well, says Cindy Dickson, offered genetic testing. All first- enlarged and damaged from top through a thousand steps for this. or four minutes [to install the says Dr. Lindsay. Registered Nurse, “vascular degree relatives of patients with to bottom that it required total It was like planning a chess game, tube], but by dropping the body Shortly after Mrs. Griffith’s patients tend to heal slower than thoracic aneurysms should be reconstruction. planning steps ahead.” temperature to 20 degrees and new custom-made graft arrived people who don’t have vascular checked for a similar aneurysm “They fabricated a whole Mrs. Griffith may not have been providing blood flow to the brain, by courier in a long cardboard disease.” with imaging to identify aortic new aorta for her,” explains aware of all the risks – the greater 02 we have up to 30 to 40 minutes.” tube, Dr. Lindsay, guided by Dr. Ms. Rahaman recalls that her problems before rupture or Ms. Rahaman, summing up risk of doing nothing versus the And while the patient is cool, so Tan and his imaging equipment, great-aunt’s postop condition was dissection occurs. Other factors the complex and innovative risk of surgery, or she may not is the surgeon. attached it to the elephant precarious. “She had a stroke and that may cause damage to the treatment that saved her great- remember the conversation about “I don’t get fussed too much,” trunk that was left hanging by had to be on dialysis, and at one walls of the aorta include aging, aunt’s life. risk with her great-niece. She A normal aorta is less than three 01 Dr. Kong Teng Tan, she says. “Obviously, some Dr. Ouzounian and began the point was not doing well with hypertension and tobacco use. Dr. Thomas Lindsay and While Ms. Rahaman is does recall going to see her family centimetres. Mrs. Griffith’s was moments are stressful. The clock delicate work of reattaching her legs. Things could have gone Dr. Maral Ouzounian are impressed with the surgical doctor a few years ago and being more than six centimetres. is ticking, and there’s minimal blood vessels.” “Everything’s either way.” • Ruptured aortic aneurysms part of the surgical team achievement, she is in complete referred to the PMCC. Two different aortic surgical that selects and performs blood flow to the brain. It’s not about catheters and wires,” That she survived “is pretty and dissections are estimated awe of the care and attention “She came to hospital in teams used two different individualized procedures the time to talk about dinner explains Dr. Tan. “The majority much due to the dedication of the to cause almost 3,000 deaths devoted to her great-aunt by the reasonable shape, but she had approaches and techniques, for patients with aortic plans. We’re very focused.” of the procedure requires fine surgeons, the ICU staff and the annually in Canada. staff at the PMCC. a very extensive problem with with the first team, led by Dr. problems. The entire operation takes catheter skills.” nurses in [wards] 4A and 4B,” “They all looked out for my her aorta,” recalls Dr. Maral Ouzounian, leaving a set-up about five or six hours, and Dr. Postoperatively, Mrs. Griffith says Ms. Rahaman. • People with aortic aneurysms aunt,” she says. “I was worried Ouzounian, a cardiac and an inside Mrs. Griffith for the second 02 Nazmoon Griffith was Ouzounian says she now does experienced partial paralysis, “All the nurses recognized her, rarely have symptoms. The that she was going to slip through aortic surgeon. repair. impressed with both the about 15 total arch replacements requiring a leak to be created in [since] she’s been there so many bulging of the aorta and other the cracks. She’s one of my “Most people who have an The surgical teams operated results of her treatment and a year. order to improve blood flow to times,” says Ms. Rahaman. “Even arteries are typically found favourite people. She brought my aneurysm have it in one section in stages, like relay race teams, the level of personal care “We’ve had other patients since her spinal arteries. Several weeks the nurses off her case came by during screening or imaging father with her to Canada when of the aorta, either close to the albeit with time for the patient to she received at the PMCC Mrs. Griffith who have needed later this leak was sealed without to say, ‘Hi.’ And many times they for other health issues, he was 17,” recalls Ms. Rahaman. heart or in the arch or in the recuperate in between. for a disease that caused the total arch elephant trunk and any paralysis, completing the told me they saw her in very such as those identified by “At [the] Peter Munk [Cardiac abdomen,” she says. “Many hospitals use one deaths of well-known actors distal aortic repair, but it is aneurysm repair. bad shape. She was really, really ultrasound or CT scans done Centre], they treated her like “The aorta leaves the heart, technique – either open surgery Alan Thicke and John Ritter. unusual to replace someone’s “We had to do some fancy sick. I would ask questions, and to investigate other diseases. she meant something, not like curves around as the aortic arch, or endovascular [inserting a entire aorta from the top to all rescue work,” recalls Dr. Lindsay. those nurses were extremely Rarely, depending on the size some low-income, old lady from then travels down through the grafted stent through the artery],” the way down to the legs.” In the end, he says, “we have knowledgeable. They really know and the location, aneurysms Scarborough. She pulled through chest and abdomen,” explains Dr. explains Dr. Ouzounian. think is best.” While Mrs. Griffith was essentially replaced this woman’s what they’re doing.” may cause pain in the upper because of the care she received. Ouzounian. “At our place, we’ve built a team Dr. Ouzounian’s team used an recovering from the arch aorta, from near her heart all She concludes: “The fact body; shortness of breath, She was treated like she was “Her aorta was very large and where every single person who open surgical technique to build a replacement, Dr. Lindsay, Dr. Tan the way down to below her belly that she is living her life and wheezing or chronic coughing; deserving of this.” [the enlargement] went all the comes in with a complex aortic new aortic arch for Mrs. Griffith. and their team were preparing button, where it divides into the continuing to be healthy is pretty and difficulty swallowing or In addition to the conventional way from very close to her heart, problem is the subject of team The colourful name of the for the second stage surgery, legs. good.” the coughing up of blood. degenerative aneurysms – the through the arch and down the review meetings: ‘Should this procedure is more Disney than the endovascular aortic artery “We did it with one major Mrs. Griffith has her own Dissections are tears that occur bulging that can result in thorax (chest) and abdomen to patient have open or endo, or a scientific: frozen elephant trunk. repair (EVAR), a relatively recent open operation and the rest summing up of the PMCC team in the aorta and generally cause ruptures – Mrs. Griffith had her legs.” combination of both?’” she says. Dr. Ouzounian cut through Mrs. procedure. through the groin. What is that saved her life. severe chest or back pain and a rare chronic dissection: a She adds: “She’s a small, petite “Because we offer the whole Griffith’s sternum and set about “The only way to fix an enlarged the innovation? That is the She points to her head and says, require emergency evaluation separation inside the aorta that woman, but she was all aorta spectrum of approaches, we can replacing her entire aortic arch aortic artery a few decades ago innovation,” he says. “There are very smart doctors and treatment. left two channels instead of one inside.” tailor for each patient what we with a customized synthetic tube was to do a major open repair,” “We’re constantly in a state of there.”

30 Peter Munk Cardiac Centre Winter 2018 31

DM182487_Pg01-50_PMCC_FALL_2017.indd 30 2017-10-13 9:42 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 31 2017-10-13 9:42 AM 01 Dr. Erwin Oechslin and Dr. Rachel Wald are members of the PMCC team providing comprehensive treatment and care for adults with ACHD. “What’s important to remember is that these patients are not fixed, they’re not cured. They’ll never be cured, only repaired. Most patients with a scar in their chest need lifelong specialized care.” Dr. Erwin Oechslin, Director, Adult Congenital Heart Disease program, the Peter Munk Cardiac Centre

forefront of the creation of Before then, this birth defect was and congenital catheter-based Dr. Oechslin, as it was modern a multidisciplinary team of fatal. interventions. The introduction medicine that created this specialized cardiologists and “Now we’re seeing our first of a dedicated heart failure cohort of patients. And he says congenital heart surgeons who wave of adults surviving in their clinic for ACHD patients led by it’s now the duty of the medical work to marry the pediatric and 20s, and we don’t really know Dr. Lucy Roche, cardiologist, community to care for these adult cardiac worlds. The clinic what’s going to happen when is one of the latest innovations patients into adulthood. is one of the oldest and largest of this cohort survives another 10 at the PMCC. “The hearts of “There have been great its kind in the world, with more years [and more], into their congenital heart patients are advances in pediatric medicine than 9,500 active patients. 30s, 40s and 50s,” explains Dr. structurally abnormal from the in the last 50 years, and now “Within ACHD, the ties to the Wald. “You’re trying to come up very beginning, and their heart we have a new generation of pediatric world are exceptionally with an educated guess of which muscle is deemed to fail,” says Dr. patients,” he explains. “So we strong because congenital complications might happen, Oechslin. as physicians and as a society heart disease was once strictly and how these can be prevented, It takes all of these experts have an ethical responsibility to a pediatric condition,” explains however management is very working together to chart deal with the consequences of Dr. Wald, originally a pediatric much an evolving process, as our out the treatment and Western medicine. I predict a cardiologist who further sub- patients teach us what we need management for these patients, further growth of ACHD patients specialized in the care of adults to be aware of.” as the work is ongoing. The in numbers and complexity in with congenital heart disease. The specialties of the team comprehensive approach and the next 10 to 15 years. Leaders Treating congenital heart members make the treatment at provision of patient-centred in health care need to find defects in adults often requires the centre truly unique. care, consolidation rather answers to the rapidly increasing an understanding of the unique Not only are there the than dilution of experiences disconnect between available complexities of each patient, congenital heart surgeons and a highly dedicated, resources and patient demand.” as many have more than one and ACHD cardiologists who multidisciplinary team make To provide the highest level medical issue. “We believe the are experts in ACHD, but the the TCCCA at the PMCC of personalized care, the best way to balance out this team also consists of cardiac a provincial, national and collaboration between these team is to have a diverse array of interventionalists (specialists international reference and multidisciplinary specialists physicians with complementary trained in catheter-based resource centre. The wealth of doesn’t stop with the heart. 01 vantage points,” adds Dr. Wald. treatment), electrophysiologists expertise has also made TCCCA Many ACHD patients have When an ACHD patient comes with expertise in heart rhythm a hub for trainees in ACHD multiple health issues involving to the centre for surgical or problems, cardiac imaging education with global impact. other organs and occurring advanced medical treatment, specialists and several others “These patients are born with simultaneously, and they require FIFTY YEARS AGO, BABIES advances in diagnosis and members of the team gather to with congenital heart disease an abnormal heart from the the care of dedicated specialists BORN WITH COMPLEX treatment, these people survive discuss the best approach for expertise to help provide the very beginning, and after the outside of cardiology. Growing into CONGENITAL HEART DEFECTS to adulthood despite their birth that individual. There is a limited most balanced patient care. surgeons remodel the heart, “Many patients have had a less than 5 per cent rate of defect, but need continued amount of medical evidence to “Each colleague contributes you end up with a very complex psychosocial issues, liver survival to adulthood, as surgical follow-up and care throughout guide therapies, as these patients his or her expertise to find the anatomy,” says Dr. Oechslin. problems or pulmonary arterial adulthood when strategies that would eventually their adult lives. are often among the first of their best treatment option for the “What’s important to remember hypertension, which is high treat many of these patients “In the last few decades, this kind to survive into adult life. individual patient,” says Dr. is that these patients are not blood pressure in the lungs, were still in their infancy or not specialty [ACHD], has really Unlike other areas of medicine, Erwin Oechslin, an ACHD fixed, they’re not cured,” he adds. so we collaborate with the you are born with available. taken off,” explains Dr. Rachel where there are many people cardiologist, Director of the “They’ll never be cured, only specialists in these areas, as well,” Today, more than 90 per cent Wald, a cardiologist with the with a certain disease who can Adult Congenital Heart Disease repaired. Most patients with a explains Dr. Oechslin. of these babies make it into Toronto Congenital Cardiac be studied to help inform future program at the PMCC and Bitove scar in their chest need lifelong The treatment and care adulthood, creating a whole Centre for Adults (TCCCA) at medical decisions, with ACHD Family Professor in ACHD. specialized care.” for ACHD patients is about heart disease new patient demographic where the Peter Munk Cardiac Centre there aren’t huge numbers of “Frequently, all of them are And although their hearts have navigating uncharted waters, there are currently more adult (PMCC). “Initially, these children patients who have reached involved in the treatment of an been repaired, Dr. Oechslin so it requires ideas from a Specialized medical teams at the Peter Munk patients living with congenital simply didn’t survive, and that’s adulthood. ACHD patient.” explains that adults with multitude of experts to develop heart disease than children – and just not the case anymore. For instance, a surgical Together, the ACHD team congenital heart disease are dynamic treatment options and Cardiac Centre lead the way globally in the medicine must now do its best to Now this expanding patient technique to help treat babies is recognized for its long- at increased risk for stenosed map out guidelines for future treatment and care of adults born with a heart keep up. population requires a specialized born with hypoplastic left heart term outcome studies, care or leaky valves, significant generations. defect The rapidly growing field of team of physicians and nurses to syndrome – which occurs when of pregnant women with arrhythmias, heart failure and For Dr. Oechslin, “it’s this team adult congenital heart disease look after them.” the heart’s left side isn’t able to heart disease, attention to early death, so it’s vital to follow approach and a pool of experts (ACHD) deals with patients To treat the rapidly growing effectively pump blood, forcing psychological aspects and end-of- them to prevent a catastrophic with passion, empathy and who had one or more structural number of ACHD patients the right side of the heart to life questions in congenital heart outcome. dedication who can find and By Daina Lawrence abnormalities of the heart in Canada, the TCCCA pump blood to the entire body – disease patients and state-of-the- These patients are “survivors of provide the best care for these present at birth. Thanks to and the PMCC were at the wasn’t available until the 1990s. art adult congenital heart surgery modern medicine,” according to patients.”

32 Peter Munk Cardiac Centre Winter 2018 33

DM182487_Pg01-51_PMCC_FALL_2017.indd 32 2017-10-06 11:59 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 33 2017-10-06 11:59 AM THE MECHANICAL HEART membrane that opens and closes “We meet several times per year, But even one that slips through silver-coated valve removed. VALVE THAT DR. JAGDISH to let in blood and prevent it and I sit on the advisory board. is too many, and problems still “They said that I’m biased,” Dr. BUTANY HOLDS IN HIS HAND from flowing back. We get presentations on various can come up, Dr. David says. Butany says. The manufacturer looks surprisingly unassuming, As a pathologist, Dr. Butany devices that are coming on the “In the worst cases, had a lot at stake: in addition about the size of a dime. Yet looks at tissues, biopsies, lab market and then we talk about unfortunately, death is where to the cost of research and as director of cardiovascular results and even autopsies to whether we see any pitfalls or the problem happens,” he says. development, by 2000 the pathology at the Peter Munk determine what went wrong. have concerns,” he says. Even patients who survive company had sold 36,000 of Cardiac Centre (PMCC), this He works closely in evaluating “We’re not supportive of one a malfunctioning device these devices worldwide. particular valve took him on a and reviewing new devices with company or another. We switch must undergo removal and Not content to let this mission around the world. cardiovascular surgeons Dr. around, and sometimes the replacement heart surgery, and accusation sit, Dr. Butany The mission was to solve a Tirone David, Melanie Munk companies get upset. We have no that’s when Dr. Butany does his prepared research papers and mystery – what was causing Chair in Cardiovascular Surgery, problem being critical when it’s sleuthing. travelled around the world to this manufacturer’s new model and Dr. Christopher Feindel, necessary,” he explains. “This particular valve was a real deliver them, including a key of heart valve to be connected Antonio & Helga DeGasperis “On that committee we also detective story. I spoke with Dr. presentation in Britain, making to infections in heart patients, Chair in Clinical Trials and have talked about follow-up, Butany and told him something the case to reconsider the resulting in their bodies rejecting Outcomes Research at University where something has already was just not right,” Dr. Feindel silver-coated valve. The team the device and in some cases Health Network (UHN) and been approved, and we find says. at the UHN in Toronto stopped death. across the city. down the road there are Dr. Butany took it from there, using them, but Dr. Butany was The mystery started unfolding Many people believe that problems. Health Canada has suspecting that the silver coating determined to trigger a global some 20 years ago, Dr. Butany doctors are highly influenced by made it very clear that they rely was the problem. It had been review. explains. drug and health-care companies, on clinicians [like those at the added by the manufacturer based Late in 1999, the United “Normally, about 2 per cent of but “those days are gone,” Dr. PMCC] to identify problems.” on the same principle that has Kingdom’s Medical Device prosthetic heart valves that are Feindel says. Pathology is at one end of doctors apply silver nitrate drops Agency heeded Dr. Butany’s implanted do get infected. You The PMCC is particularly the testing process that all to the eyes of newborn babies – findings, issuing a warning make something by hand or with careful about which devices medical devices must undergo, to ward off infection. against the valve. Australia and machinery, and somewhere along make the grade, Dr. Feindel adds. in many cases following the His pathology research led New Zealand followed suit. the line, if the sterilization is “From time to time a new procedures of the U.S. Food and him to suspect that rather than “One day, about three years not adequate, you can get bugs device will come on the market, Drug Administration. (Health protecting against infection, the after I had my first concerns coming in,” he says. and we’ll start to see one-off or Canada tends to adopt the same silver coating on the valves was regarding the valve, I got a call In the late 1990s, one of the anecdotal situations where it standards.) toxic to cells in the heart muscle. from the manufacturer saying manufacturers brought out a isn’t working quite right. Over At the other end, before devices “I started talking to the that the device was about to new model. It was offered to time we might see a pattern,” he even reach the market, they are manufacturer and continued be withdrawn. They made the leading heart institutes at no says. tested rigorously. Dr. Feindel says [investigating],” Dr. Butany says. public announcement half an extra cost because it included Dr. Feindel also sits on a Health he can think of only a handful At one point, he presented them hour later, that morning,” Dr. only a small improvement – a Canada committee that reviews of situations in 30 years where with the unusually high numbers Butany says. coating of silver along its edge heart-related medical devices. devices didn’t work properly. of patients who had to have the The process for reviewing that was intended to prevent devices is always itself being infection. reviewed and fine-tuned, Dr. Trouble is, more patients than Feindel says. usual actually had infections “It’s a fine line between allowing after receiving this device. people to use new devices and Instead of the normal percentage being cautious,” he explains. of patients whose valves had to For the future, “I think there are be replaced, within months the probably ways you could tighten numbers kept going up. the follow-up. There have been “When we had eight subtle changes in new trans- [infections], I said, ‘This is too catheter valves [implanted into much.’ Unfortunately, prosthetic aortic valves], for example,” Dr. heart valves behave differently Feindel says. 01 in different people,” Dr. Butany “We’ve learned a lot over the says. last few years, so if there’s an While Dr. Butany knew the issue with one, we need to know problem needed attention, if it’s a one-off situation, or are he didn’t think dealing with there more cases like it?” this valve would become the Pathologists’ puzzle: cornerstone of his life’s work. There was a great deal at stake, though, not only for some of the mystery of the silver- over 55,000 people who have 01 Discovering the heart valves implanted every problem with this year, but also for the hospitals mechanical heart valve is part of the PMCC’s that need to make sure the coated heart valve dedication to rigorous devices work and the companies testing protocols. that invest tens and even Dr. Jagdish Butany and the Peter Munk Cardiac Centre’s determined team hundreds of millions of dollars in 02 From left: Drs. Tirone of detectives work to ensure the safety of novel cardiovascular devices developing valves. David, Jagdish Butany Costing at least $4,000 each and Christopher Feindel in Canada, synthetic heart valve strive to fine-tune the looks deceptively simple. It’s 02 process for reviewing By David Israelson an outer ring with a disc or a new devices.

34 Peter Munk Cardiac Centre Winter 2018 35

DM182487_Pg01-50_PMCC_FALL_2017.indd 34 2017-10-13 9:42 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 35 2017-10-13 9:42 AM General Hospital anesthesiologist Dr. Annette Vegas, Professor of A special Anesthesia, set out to create a virtual TEE website that would allow people to learn how to ‘recipe’ where perform the procedure without patient involvement. “My personal motivation for PIE will get creating PIE was to provide a state-of-the-art, interactive medical education, free for anyone,” Dr. Tait explains. “All you TEE over the world, people are using these modules as part of their Unique user-friendly modules developed by the training. PIE doesn’t run courses, but we create resources for other Peter Munk Cardiac Centre provide state-of-the art people who do.” medical education, enabling students worldwide to The user-friendly modules learn about and develop skills in complex procedures offer instructional videos and a 3-D model of the heart that without real patients users can drag and turn to view various angles and cross- sections of the organ, simulating By Chris Atchison real-world TEE. Various other modules allow students to learn about topics such as heart valve MOST OF US ASSUME THAT the anesthesiologists tasked with assessment, obstetric anesthesia WHEN A MEDICAL STUDENT conducting the procedure. and heart failure, while also using COMPLETES A DEGREE IN ONE “You can’t practise on people virtual tools to examine other AREA OF SPECIALIZATION because sticking the probe areas of the body such as the liver such as anesthesiology, that down someone’s throat isn’t and the spine. student is ready to work medical pleasant,” says Dr. Gordon Tait, The TEE Standard Views magic in a clinical setting. That’s Assistant Professor of Anesthesia module is available in nine somewhat true, but with an and Manager of Perioperative different languages, including important caveat. Interactive Education (PIE) at English, and is used daily by over Like any professionals doing Toronto General Hospital. 1,500 people in 200 countries. complex work, doctors need time “In cardiology, it’s also not done “The one thing I like about and practice to perfect their craft. commonly because you have to [the PIE website] is that it’s very But when it comes to mastering be heavily sedated, so the great democratic,” Dr. Tait adds. “Every key technical skills in medicine, majority of TEE is done in the country in the world, no matter getting practice time can be operating room on patients about how well off they are, has access complicated. to have cardiac surgery.” to the Internet. They have the Simply finding patients on About a decade ago, Dr. Tait same access in India or African whom to perfect diagnostic took it upon himself to overcome countries or South America as testing skills requires a mixture that challenge. [they do] at Yale University or of the right timing and the right His idea was simple: What if Johns Hopkins University in the cases. anesthesiologists had a virtual United States. “If you are working on a day platform for practising TEE, “It levels the playing field for when it’s all coronary bypass rather than working on live medical education.” surgeries, and there’s no valve patients? So the PIE team in Because the platform is 01 pathology, then you don’t gain collaboration with Toronto currently built in Flash Player any experience imaging and analyzing abnormal valves,” explains Dr. Wendy Tsang, 01 The work of – the soon-to-be-obsolete of all skill levels the process in is difficult, especially once YouTube videos demonstrating a researcher, cardiologist Drs. Gordon Tait, multimedia software for viewing major detail, down to buttons physicians have finished their echocardiography that are free to and staff physician in the Annette Vegass, rich media on the Web – Dr. Tait being pushed and adjustments training,” she says. “Trainees in the public as just one example. Echocardiography Lab of the “The one thing I like most about Dr. Massimiliano is attempting to fundraise in being made to the virtual TEE smaller centres and individuals “This is a step forward from Peter Munk Cardiac Centre Meineri and Wendy order to upgrade the platform equipment in order to simulate a practising in the community may someone thinking they have an (PMCC). [the PIE website] is that it’s very Tsang involving PIE to HTML 5, the next generation real-world experience. not be able to go or have access to interesting video and uploading The challenge is even greater democratic. Every country in the fills a major gap software for playing online audio Previously, she says, a centre willing to offer them the it to YouTube,” she says of when it comes to practising in helping doctors and video. anesthesiologists or cardiologists time to learn and practise. There the PIE website. “This has a procedures such as transesopha- world, no matter how well off they and students learn Dr. Tsang – who was a learning TEE, or any diagnostic was a major gap that needed to more structured educational geal echocardiography (TEE), new technologies contributor to 3-D TEE imaging procedure, would be limited to be filled.” component. and techniques. where a tiny probe is fed down a are, has access to the Internet…it sections with anesthesiologist Dr. the knowledge and experience From Dr. Tsang’s perspective, “It also demonstrates how you patient’s esophagus in order to Massimiliano Meineri, Associate of the doctor providing the upgrading the technology is can reach out to people who gain a clear and unobstructed levels the playing field for medical Professor of Anesthesia – points instruction. The PIE website essential at a time when even can’t come [to your hospital or view of the heart. out that the website helps removes potential variance in the the most complex medical university] for training. It’s free An indispensable tool, TEE is education.” standardize TEE instruction education process. instruction is migrating into for anyone and has quality behind relatively challenging to master, Dr. Gordon Tait, Manager, Perioperative Interactive Education, and student experiences. And “To find the time to learn new the digital realm. She points it. You can’t necessarily guarantee making practice time crucial for Toronto General Hospital that includes showing students technologies or techniques to the plethora of detailed that when you go online.”

36 Peter Munk Cardiac Centre Winter 2018 37

DM182487_Pg01-51_PMCC_FALL_2017.indd 36 2017-10-06 11:59 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 37 2017-10-06 12:00 PM Recruiting and retaining the best and the brightest

Multidisciplinary research and creative thinking aid the Peter Munk Cardiac Centre in its relentless search for top talent

By Mary Gooderham

THE PETER MUNK CARDIAC a disease that we’ve been treating CENTRE (PMCC) HAS BECOME for some time,” he says, noting A POWERFUL CENTRE FOR that a good deal of research “has INNOVATIVE MEDICAL plateaued” in cardiovascular RESEARCH that attracts disease. “It’s time for a fresh look scientists from all over the and a fresh perspective, and I world. “The multidisciplinary thought that the people here were environment allows cross- the ones who might be able to do fertilization of ideas by that.” stimulating interaction across Dr. Lawler, a Boston native various medical specialties and who attended medical school scientific disciplines. This feature and completed his residency at of our environment is attractive McGill University in Montreal, to bright, creative people,” was impressed with the diverse says Dr. Michael Domanski, group of people at the PMCC Cardiology Division Director who have expertise in clinical at University Health Network trials, including epidemiologists, (UHN) and Mount Sinai biostatisticians, regulatory Hospital. scientists and administrators. Dr. Domanski, a specialist “Lots of aspects of science are 01 02 03 in advanced heart failure and a team sport, but having the transplant cardiology, made the right team is really essential to move from the Icahn School of doing these large clinical trials Medicine at Mount Sinai Hospital and translational studies,” he establishing five new chairs and look out over the landscape and 01 Dr. Patrick Veit-Haibach patient population with all sorts I’ve been,” he says. “It can be more operation do more for medicine in New York to the PMCC says, adding that international four centres of excellence. “Our choose the PMCC tells you about is a radiologist and nuclear of cardiovascular indications,” as political.” than most physicians ever do,” “because it looked like a chance recruitment is part of an overall vision is to be the best heart the draw that we have. He could medicine physician who well as its enthusiasm for using The fact that the new recruits at he remarks. “Those people to make a difference in terms trend to “break down the borders” centre in the world, and you can’t have gone anywhere.” came from the University molecular imaging in all sorts of the PMCC have associations with can buy a yacht and dock it in of research and also in patient in medicine. be that without having the best Another new recruit, Dr. Patrick of Zurich. He says the trials. institutions outside of Canada Monaco; instead, they’re making care and teaching,” he says. “The “One of the richnesses of the people.” Veit-Haibach, a radiologist and interdisciplinary approach “It makes it interesting,” he says, will benefit research there, says a difference in their community commitment of the organization medical community here is the Dr. Rubin says the new nuclear medicine physician, at the PMCC inspires noting that he’s pleased to get a Dr. Veit-Haibach, who expects to and internationally.” to innovation is expressed by its diversity of backgrounds that recruits in turn are attracted came to the PMCC’s Joint teamwork and innovation. good deal of academic time at connect with research fellows at Adds Dr. Domanski: “I would leadership.” people bring from across the by the PMCC’s vision, its Department of Medical Imaging the PMCC, which has a strong the University of Zurich. like the PMCC to be a hotbed of 02 Dr. Michael Domanski Dr. Patrick Lawler, a cardiologist world,” Dr. Lawler says. “It’s multidisciplinary approach, in April from the University of focus on translating basic science Dr. Domanski says that intellectual ferment and progress is a specialist in advanced who joined the PMCC’s emerging important to continue that.” its cohesive program and a Zurich. As director of Positron heart failure and transplant to clinical science. “There’s multidisciplinary research in research that improves public cardiovascular clinical trials Dr. Barry Rubin, Medical “constant and unremitting focus Emission Tomography/Magnetic cardiology. The PMCC’s something to build up here, so we is “implicit” and “critical to health. That’s what we’re all here group in April, was attracted Director of the PMCC, says that on innovation.” He calls the Resonance imaging (PET-MRI), multidisciplinary setting can understand disease, where it any endeavour” in the field of for – to turn back the tsunami of from his position at Brigham recruiting is among the stated substantial number of recruits his clinical research focus is inspired his move from New comes from and how to intervene cardiology. “There are few things heart disease.” and Women’s Hospital and goals of the Peter and Melanie from the U.S. “the reverse of the combining molecular imaging York City. successfully to bring relief to that you can do without any The new faces at the PMCC Boston Children’s Hospital, as Munk Charitable Foundation’s brain drain,” made possible with strategies, such as allowing patients.” appeal to colleagues in other will bring “dramatic change in well as Harvard Medical School third donation to the PMCC in substantial funds from donors to physicians to assess the profusion, 03 Dr. Patrick Lawler, who Interdisciplinary exchange is areas, from biostatistics to cardiac the way that we manage patients in Boston, because the centre 2011, along with retaining the the PMCC, including the Munks. function and viability of blood was attracted to the PMCC “very much encouraged” in his surgery to clinical epidemiology.” with heart disease,” Dr. Rubin encouraged creative thinking and best and the brightest. He says, for example, that Dr. flow at the same time. “You can because it encouraged field, Dr. Veit-Haibach says, and The people at the PMCC are predicts. “For all the investments encouraged taking scientific risks. “We’ve been unbelievably Lawler “is truly at the cutting follow the physiological pathway creative thinking, believes the PMCC inspires teamwork. particularly important, he says, that are made and all the science, “It seemed like there was a spirit successful at doing that,” he edge,” and “every major heart of diseases,” he says. having the right team is key “Everybody’s really collaborative including the philanthropists who the single most important thing of wanting to do different things says, noting that key elements centre” tried to hire him. “For Dr. Veit-Haibach is excited to to doing large clinical trials and open to new ideas; that’s not make it happen. here is the people we recruit – no and trying different approaches to of the strategy have included somebody with his pedigree to be at the PMCC, given its “large and translational studies. always the case in places where “Those who finance this question.”

38 Peter Munk Cardiac Centre Winter 2018 39

DM182487_Pg01-51_PMCC_FALL_2017.indd 38 2017-10-06 12:00 PM DM182487_Pg01-51_PMCC_FALL_2017.indd 39 2017-10-06 12:00 PM Ad-Final-GuidingYourBusiness.pdf 13 2017-08-24 3:44 PM

C

M

Y CM The right test, MY CY at the right CMY K time

As the appetite grows for medical testing, a palatable app is feeding physicians timely Guiding your business information on the path to success. By Shannon Moneo

Thorsteinssons is proud to support the Peter Munk Cardiac Centre and to share in their vision of integrating excellence

into every aspect of client care. Cardiologist Dr. Sacha Bhatia and his team led the Echo Wisely trial, which examined ways to reduce the number of unnecessary echocadiograms being performed. The initiative was funded by the PMCC Innovation Committee. thor.ca Winter 2018 41

DM182487_Pg01-51_PMCC_FALL_2017.indd 41 2017-10-06 12:33 PM DM182487_Pg40_PMCC_FALL_2017.indd 40 17-10-06 1:24 PM INNOVATION CAN BE LIFE- SAVING, but if new and more productive ideas never make it beyond the lab or test stage, it “One thing we know is that some people get care becomes innovation inaction. Within the fast-evolving world of they probably don’t need…the basic premise medicine, as new technologies, drugs and procedures are becomes: ‘How do we make sure the patient gets the unveiled each day, having solid proof that a new innovation tests they need?’” works as promised usually leads Dr. Sacha Bhatia, Cardiologist, Women’s College Hospital and University Health Network to greater adoption. The Peter Munk Cardiac Centre (PMCC) is putting such innovations into action, recently finishing a nine- hospital study where an online application was used to guide unnecessary, care in a setting the e-mail feedback informed the just gave them data in a very physicians in the appropriate use where health-care resources are physicians how their peers were thoughtful way,” Dr. Bhatia says. of echocardiography. stretched. “The basic premise doing and which physicians were “By giving doctors information, When Dr. Barry Rubin becomes: ‘How do we make sure ordering fewer tests. “Doctors we significantly changed their was asked in 2013 by the the patient gets the tests they often don’t get feedback on behaviour. It’s about showing Government of Ontario to need?’” Dr. Bhatia asks. how they’re doing,” Dr. Bhatia doctors how they practise in examine the appropriate Echocardiography uses notes. That information became a way that’s easy to digest, use of imaging tests, such as ultrasound to create images of significant because the doctors changing their practice for the echocardiography and magnetic the heart in order to examine became more aware of how their better and improving their resonance imaging, he wanted its blood supply, determine how patients were later doing and performance.” no outside interference and the large the heart is, how well it how much treatment cost. Or as Dr. Rubin says, “It’s one freedom to produce an honest contracts and how the valves In 2013, a University of Toronto thing to put together a recipe report. The stakes were rather function. The test, using an study found that between and another thing to follow high because Canada spends ultrasound probe and electrodes 2001 and 2009, the rate of it.” He adds that Dr. Bhatia more than $2.2-billion annually attached to the skin, is done echocardiography increased by is putting into practice the on such diagnostic imaging. when people are concerned 5.5 per cent over the eight years, recommendations from his Just a 10 per cent decrease in about, for example, heart disease, a rate that was adjusted for the 2013 report. “He’s a superstar,” unnecessary testing would save dizziness, irregular heartbeat rising number of older citizens Dr. Rubin says. “His work $220-million each year. What or shortness of breath. It costs and accelerating rates of disease. and the recommendations my Dr. Rubin, the PMCC’s Medical approximately $100 for the Dr. Bhatia attributes the rather expert panel made align. The Director, and his Expert Panel physician to read the test results, high growth rate to patients’ problem had been that there on Appropriate Utilization of plus another $100 for the actual requests for tests and how were guidelines out there, but Diagnostic and Imaging Studies test, Dr. Bhatia notes. physicians practise, meaning no mechanism to put them into found is that 10 per cent to 30 While a research fellow in they don’t refrain from ordering action. He used technology per cent of imaging tests are cardiology at Massachusetts tests. to deliver a solution in a very done for inappropriate reasons. General Hospital and a research After returning to Canada, Dr. effective way.” The upshot is “When you focus on fellow at Harvard University Bhatia began a similar 18-month that doctors will order fewer electrocardiography, it’s a from 2011–13, Dr. Bhatia learned study in 2014 at nine hospitals in tests, saving money, increasing $140-million enterprise in of an “appropriate use criteria” Toronto, Kingston and Boston, access and reducing wait times Ontario, annually. If one-quarter guideline that he combined with involving almost 180 clinicians for patients who require a heart of those tests were not carried a pocket card that described who were broken into two ultrasound. out, it would produce savings of the criteria in the context of groups. Dr. Bhatia, who also earned $35-million each year,” says Dr. common clinical scenarios and One group had no contact with an Innovation in Quality Award Rubin, a vascular surgeon and twice-monthly e-mail feedback Dr. Bhatia and his team. The last year, would like to apply also a Professor of Surgery at the on the appropriateness of test second group got a YouTube the process to other tests. “It University of Toronto. “The goal orders. When used by a study video outlining the appropriate doesn’t have to be limited to is to control costs by ensuring group, there was a 26 per cent use of echocardiography and echocardiograms. It could be tests are done only for the right reduction in echocardiography was given access to an online used for stress tests, CTs, MRIs, reasons, in a safe environment, orders. In 2013, Dr. Bhatia was appropriate use criteria even for the prescription of by individuals who are trained to awarded the Arthur E. Weyman application for their phone. drugs.” carry out and interpret the tests.” Young Investigator’s Award Research co-ordinators would And as in the earlier U.S. study, So the problem then becomes: by the American Society of record how often and why they Canadian physicians appreciate “What are the right reasons?” Echocardiography and the Young ordered echocardiograms, and the rare feedback. “I think Enter Dr. Sacha Bhatia, a Investigator Award from the the data would be delivered to there’s a real appetite to give cardiologist at Women’s College American College of Cardiology Dr. Bhatia. His team would input doctors their performance data Hospital and at University for his work. the information, and each month and how they can improve,” Dr. Health Network. “One thing “We used very simple the physicians would receive an Bhatia says. “No one wants to be we know is that some people educational material, looked e-mail telling them whether the mediocre.” get care they probably don’t at their order patterns and ordered test was appropriate or need,” he says. The danger examined the appropriateness,” why it wasn’t necessary. As the (The results of the Echo Wisely study then becomes that patients he says. Physicians were provided trial proceeded, there was a 25 were published in the Journal of the will get false positive results with clear guidelines and per cent drop in the number of American College of Cardiology on or benign conditions will be recommendations, based on key unnecessary echocardiograms. August 21, 2017, a high-impact flagged, leading to more, often indicators. But more importantly, “There were no incentives. We medical journal.)

42 Peter Munk Cardiac Centre

DM182487_Pg01-51_PMCC_FALL_2017.indd 42 2017-10-06 12:33 PM DM182487_Pg43_PMCC_FALL_2017.indd 43 17-10-06 1:50 PM a stroke or a heart attack. The balance of the two.” she didn’t eat better and get more to see if people’s blood pressure best way to beat the problem is Dr. Nolan developed REACH exercise then she’d have to start dropped and cholesterol levels through meaningful change, he (Reducing risk with E-based taking pills. “And I didn’t want to improved. That would indicate says. support for Adherence to lifestyle do that,” she says. that lifestyle changes had been While many hospitals and Change in Hypertension), a The program was designed as made. private centres have tried to help comprehensive e-counselling a series of counselling sessions The results were fascinating, people kick bad habits through program to help people make that take place once a week for says Dr. Nolan. Systolic blood internet-based programs, most permanent changes to their the first four months, then once pressure, which measures the of these haven’t been designed lifestyle or “self-care behaviours”. every two weeks for the next four pressure in one’s arteries during to provide the type of support Their team included numerous months and then once a month heart contractions, was lower patients receive in face-to-face experts, such as dietitians, for the last four months. The goal by 10 millimetres of mercury, as counselling, says Dr. Nolan. psychologists, doctors, fitness was to break old habits by the end compared to six for the control Many Web-focused counselling experts, pharmacists and of the year. group. Another kind of blood programs are either interactive or scientists, to create self-help For Ms. Kononen these regular pressure, pulse pressure, was automated – not both. videos that covered every aspect sessions were key. Reminders also significantly reduced in the With the interactive programs, of a person’s lifestyle. – through instructional videos, e-counselling group. someone might instant message Key questions that patients e-mails and other forms of Patients’ Framingham Risk with a counsellor and discuss might have about lifestyle change communication – on how to eat Score, which measures the risk their issues, but when the were answered in this program. better and exercise more allowed of experiencing cardiovascular conversation ends, the patient is Not sure how to read nutrition her to slowly change her habits. disease (such as heart attack or left without support about what facts on labels? Then take a No one made her feel badly when stroke), was also down by about to do next. With the automated video tour of a grocery store with she stumbled, which made her 2 per cent, while people in the education, someone might input a dietitian who shows people want to improve even more. e-counselling program increased personal information on a website how items are categorized, what “You can’t change everything their activity by walking about and get articles and data tailored labels mean, how to navigate overnight, but this program gave 1,200 steps per day more than the to them, but when the reading nutritional guidelines and more. me control and empowered me,” control group. ends, there’s no clear idea on how Need an exercise regime? Watch she says. “They gave me a series of “We saw significant differences,” to apply the information to their a fitness expert give step-by-step small things to change that, over he says. “We wanted to increase personal situation. instructions on how to set up a time, made a huge difference.” the degree to which people ad- “Our programs often fail to plan. Starting in 2012, the program hered to self-care behaviours [in provide guidance as someone Virpi Kononen, a Toronto-based was in the testing stage for four order] to manage hypertension, interacts with a program within IT worker, swears by the program. years via a controlled trial, where and that’s exactly what they did.” a single log-on session, or as In 2015, she was suffering from some people received regular Ms. Kononen saw big changes, we log on time after time,” says high blood pressure and a ringing counselling and others followed too. After a year, her blood Dr. Nolan. “We had to create a in her ears. She was told that if Dr. Nolan’s program. He wanted pressure went back to normal, the ringing stopped, she’s walking an average of 7,000 steps a day – 2,000 more than she did during the trial – and she says she’s heathier than she has been in years. For Dr. Nolan, the next step is to enroll all patients with hypertension into the program, 01 but he also wants his program to be used nationally. “Our goal is to look for partners who want to work with us, who EVERYONE KNOWS THAT A and then be left to fend for can offer this on a population- HEALTHY DIET AND REGULAR themselves. Some might change wide basis,” he says. “We want A breakthrough EXERCISE CAN LEAD TO A their behaviours for a short to continue making sure that we LONGER LIFE, but for most period, but most would revert to can demonstrate the effectiveness people, it’s nearly impossible old habits. of this for not just reducing risk in lowering to break bad lifestyle habits. In “They’d get educational sessions factors for heart disease, but 2010, Dr. Robert Nolan, Director that would last a few weeks, but also that we can help improve of the Cardiac eHealth and giving people information was not everyone’s quality of life.” systolic blood Behavioural Cardiology Research sufficient to help them feel ready Unit at Peter Munk Cardiac and confident to sustain lifestyle Centre (PMCC), set out to change change,” says Dr. Nolan. “Without that by helping patients connect support to develop skills for 01 Dr. Robert Nolan, second pressure heart-healthy lifestyle change putting a change plan into action, from the left, and his team at the PMCC work to find to their personal goals for living it was hard to shift old habits ways for patients to deal with well. beyond a few weeks.” A new e-counselling program is proving that with the hypertension by creating Over the last seven years, Dr. For patients with hypertension, right self-help support and education, people can make important and long-lasting Nolan has been devising ways to short-term changes aren’t good lifestyle changes. healthier lifestyle choices and – hopefully – live longer help patients with hypertension enough. If high blood pressure create meaningful and long- is not treated with a better diet, 02 For Toronto IT worker Virpi lasting lifestyle changes. In more physical activity, smoke-free Kononen, regular sessions were the past, people would have living and taking medications as the key to success in managing By Bryan Borzykowski 02 consultations with a specialist prescribed, then it could lead to her high blood pressure.

44 Peter Munk Cardiac Centre Winter 2018 45

DM182487_Pg01-51_PMCC_FALL_2017.indd 44 2017-10-06 12:38 PM DM182487_Pg01-51_PMCC_FALL_2017.indd 45 2017-10-06 12:38 PM 01 01 Dr. Keyvan Karkouti, left, Dr. Stuart McCluskey To give or and Cielo Bingley, a Perioperative Blood Conservation Co-ordinator, work together to find ways not to give to ensure that with a limited blood supply, opportunities are found to conserve Rather than making it common practice, an wherever possible. innovative procedure can determine if a patient really needs a blood transfusion

DROPS OF By Shannon Moneo BLOOD DATA

900,000: Average number of DR. VIVEK RAO COULD ONLY “The algorithm allows us, early blood?” The questions drill units of blood collected each year TALK BRIEFLY. The Division at the bedside, to identify why down to appropriate treatment, in Canada, outside of Quebec. Head of Cardiovascular Surgery, patients are bleeding, and once be it no blood products, the and the Peter Munk Cardiac that’s identified, to find therapies use of platelets, plasma or 5: Average number of litres of Centre Chair in Advanced to target abnormalities we cryoprecipitate, a frozen blood blood in a person’s body. Cardiac Therapeutics, had just identified,” says Dr. Karkouti, product prepared from plasma. completed a heart transplant, who is keenly aware of the When heart surgery is 450 millilitres: Amount of but the 52-year-old patient was algorithm’s value. performed, heavy bleeding can blood that goes into a single bleeding, and Dr. Rao had to Between October 2014 and May occur. The more blood that is donation. Often referred to as a return to the patient. 2015, a randomized controlled lost during surgery, the worse “pint,” a blood donation is 450 Beyond the complexity of trial of the point-of-care–based the outcome for the patient. mL, not the actual 570 mL in a operating on the body’s life-giving transfusion algorithm was Conditions that lead to excessive pint. organ, cardiac surgery poses the tested at 12 Canadian hospitals. bleeding during surgery include danger of difficult-to-manage None of the sites previously complex heart surgeries, such as 42 days: Maximum shelf life for or persistent bleeding. In the used point-of-care testing for transplants, that result in longer red blood cells collected through case of Dr. Rao’s patient, a novel bleeding management during times on the heart-lung machine; blood donations. Most blood is technique that addresses blood cardiac surgery. During the complicated, emergency heart sent to hospitals within a week. transfusions was successfully seven months, the algorithm surgery; and patients who Platelets have a five-day shelf used. Employing what’s called a was used for 7,402 patients were taking blood-thinner life. Plasma can be frozen, having point-of-care algorithm, Dr. Rao having coronary bypass surgery. medications, Dr. Karkouti says. a longer shelf life. and his team determined that Overall, the point-of-care Use of the heart-lung machine the man’s platelets – the cells algorithm reduced red blood cell plays a significant role in Every 60 seconds: How often, needed to help blood clot – were transfusions, platelet transfusions degrading the patient’s blood. on average, someone in Canada dysfunctional and so they were and major bleeding following During open heart surgery, the receives blood or a blood replaced. cardiac surgery. heart has to be stopped, so the product. “The point-of-care testing For Dr. Michael Farkouh, the patient is hooked to the heart- enabled the team to administer “out-of-box” thinking that led lung machine, which becomes 52%: Proportion of Canadians only the required platelets to this valuable algorithm is responsible for delivering who say they or a family member and not a wide range of blood truly innovation in action. “It’s a oxygenated blood to the body. have needed blood or blood products that would ultimately novel, very cost-effective way of Blood flows out of the heart’s products for medical treatment. be unnecessary,” Dr. Rao says. As improving outcomes,” says the right atrium, through the well, Dr. Rao discovered a source Chair of the Peter Munk Centre machine and then the now- based on what they see, Dr. Rao to receive the point-of-care test hospitals do not pay for the blood better outcomes because we can 1 in 10: Number of people of bleeding, which was also of Excellence in Multinational oxygenated blood flows back says. If Method A doesn’t work, results. “We’re an impatient products they use, there is a implement interventions that admitted to hospital who receive controlled. “The patient did well Clinical Trials. into an aorta. But as the blood Method B is implemented, then bunch,” Dr. Rao says of his fellow cost. In Ontario, the provincial reduce transfusions,” says Dr. blood. subsequently,” he says. With a limited blood supply courses through the machine, Method C, using the process of cardiac surgeons. “They’ve told government pays Canadian Blood Rao, who believes U.S. hospitals Point-of-care tests are designed and a push to conserve such the circuitry diminishes the elimination, not an algorithm. me, ‘You want me to wait?’” The Services. will be interested, given that they Heart transplant: Requires to be used at or near the spot resources throughout the blood’s clotting factors, which The bleeding could be caused by test also costs between $50 and Blood is an expensive, limited pay for the blood they use. 40 units of blood, 30 units of where the patient is located, don’t health-care system, Dr. Farkouh, is one reason why patients need a torn suture line, or the patient $100 per patient, more than resource and carries serious risks. But it’s early days. “With platelets, 25 units of plasma and require permanent and dedicated a cardiologist, foresees broad more platelets. As well, synthetic may have dysfunctional platelets. standard lab tests, primarily due Each unit costs roughly $650 the management of bleeding 20 units of cyroprecipitate. space and are performed outside appeal for the algorithm. grafts, hypothermia and surgical The beauty of the algorithm to costs of chemical compounds, to $1,550 to deliver from the patients, there are still lots of of clinical laboratories. An “We have the ability to tailor trauma can affect blood’s clotting is that it points surgeons in the Dr. Karkouti says. donor to the patient. Forecasts questions,” Dr. Karkouti says. 2: Units of blood needed for hip algorithm is a set of rules to transfusions in patients,” he says. ability and may lead to the need right direction. Over the last two years, the also predict that the demand “The algorithm has improved replacement surgery. be applied to calculations or The algorithm works by for transfusions. “So far, I’ve been impressed algorithm has been used for may outstrip supply in the near our care, but there are issues problem solving. determining if platelets, red Another operating room with the point-of-care algorithm about 3,000 cardiac surgeries at future. As well, transfusions still to resolve of how to best 6: Units of blood needed for At the Peter Munk Cardiac blood cells or plasma are dilemma is how long a physician to treat bleeding disorders,” Dr. Toronto General Hospital, Dr. can lead to life-threatening manage patients. There’s still a heart surgery. Centre (PMCC), the algorithm needed via a flow chart. After waits before treating the Rao says. “We can now target Rao says. While the costs add complications, such as infections, fair amount we don’t know about addresses blood loss after a blood sample is rewarmed, bleeding, Dr. Karkouti says. the actual problem, rather than up, there can actually be savings acute hemolytic reactions, acute why people bleed. The algorithm 20: Units of blood needed for a surgery and allows faster questions are asked, such as: Watching and waiting to see using a shotgun approach. We’re because fewer blood products, lung injury and volume overload. has taken us a fair ways, but we burn patient. results for targeted therapy, “What are the clotting defects?” if the bleeding slows is one treating a problem – the bleeding such as red blood cells, platelets Moreover, a proportional relation still don’t know all the answers.” says Dr. Keyvan Karkouti, or “How much blood loss has approach. – not the symptom.” and plasma, are used during between blood transfusion Which leaves the hospital door 50: Units of blood needed for a Site Chief of Anesthesiology occurred, based on the weight of Typically, surgeons first use One minor drawback has been transfusions, Dr. Karkouti says. and mortality has been noted. open for further innovation in vehicle-crash patient. at Toronto General Hospital. sponges used to absorb patient Method A to stop bleeding, the five or 10 minutes required Even though Canadian “The algorithm does lead to action.

46 Peter Munk Cardiac Centre Winter 2018 47

DM182487_Pg01-51_PMCC_FALL_2017.indd 46 2017-10-13 10:25 AM DM182487_Pg01-51_PMCC_FALL_2017.indd 47 2017-10-13 10:25 AM met a fellow dog-owner who just increasing every year.” made anti-oxidants. They fell Patients face little risk from their A radiologist into conversation and were soon temporary radiation exposure working together, making anti- and “enormous benefits,” indeed oxidants that could be taken in a growing number of procedures stirs up a advance of radiation exposure, in can only be done by imaging- order to lessen DNA damage. guided techniques, including The result was an anti- delivering chemotherapy agents vitamin oxidant cocktail developed in to parts of the liver. collaboration with researchers Meanwhile, medical at Dalhousie University that professionals performing includes quercetin, extracted procedures such as fluoroscopy cocktail to from apple skins. The cocktail, and CT scans are exposed to which Dr. Murphy calls Coramed continual low doses of radiation, in honour of his dog’s role in yet don’t see the danger, he protect against the discovery, is currently in comments. “No one has invented clinical trials. After extensive the perfect protection as yet – research, the first clinical that’s for sure.” radiation study was carried out using 10 The International Commission patients undergoing diagnostic on Radiological Protection radiation and was funded by has suggested new exposure exposure donors who supported the Peter limits that are one-seventh of Munk Cardiac Centre (PMCC) the previous average annual Innovation Committee. level. But Dr. Machan notes A chat with his mother-in-law and a walk with his “Without that, we wouldn’t there is “tremendous individual dog gave this neuroradiologist the idea to use anti- be at this stage; it was a very, variation in how people respond very important step for us,” says to radiation, and the idea oxidants to help lessen the dangerous after-effects Dr. Murphy, noting that the of a threshold is somewhat from life-saving radiation trial showed the premedication arbitrary.” His goals are to treatment to be beneficial in reduce the amount of radiation reducing DNA breaks in the given off by imaging devices, blood of patients exposed to improve radiation shielding and By Mary Gooderham diagnostic radiation. introduce innovative protective The research is being closely measures, such as Dr. Murphy’s watched by clinicians such premedication treatment. SURGERY PERFORMED dosage. But it’s impossible to as Dr. Lindsay Machan, an “It’s one more step,” he says. UNDER X-RAY GUIDANCE avoid some exposure, he says. interventional radiologist at “There’s no doubt in my mind HAS TRANSFORMED MODERN “It’s a risk we bear because of Vancouver Hospital who has that it will become a product.” MEDICINE, allowing for our vocational committment to experienced occupational The next study of Coramed minimally-invasive operations patient care.” radiation-induced cataracts will involve testing it on (from neurosurgery to Disturbed by reports of injuries and lost the sight in one eye interventional radiologists, gastroenterology procedures), among his colleagues, Dr. as a result of cataract surgery. cardiologists and other medical reduced pain and shorter Murphy found the answer to the He says that the anti-oxidant professionals who work in a field recovery periods for patients. problem in a chat he had with premedication is an “exciting of radiation, says Dr. Murphy. It also means lower costs to his mother-in-law seven years advance” in the effort to He expects one of the largest the health-care system. But ago, as she prepared for breast reduce the impact of radiation markets for the product to be X-rays also subject patients, cancer treatment. She showed in imaging-guided surgery. airline crews, who are exposed and especially doctors, nurses him a list of things she’d been “The data are impressive and to high levels of solar radiation and technologists, to ionizing instructed not to take before encouraging.” from flying at high altitudes, radiation, causing molecular radiation therapy because they Dr. Machan says that especially on polar routes. changes in the body’s DNA that could reduce its effectiveness. minimally-invasive procedures His research has been have been linked to elevated “They were all anti-oxidants,” are “exploding” in fields such recognized by the Society of risks for cataracts and cancerous recalls Dr. Murphy, who, after as cardiology, orthopaedics, Interventional Radiology, tumours. viewing the list, then went on vascular surgery and pain which gave him its Leaders “It’s scary; we are exposed a walk with his dog Cora and medicine. “The numbers are in Innovation Award in 2015. to vast amounts of radiation Murphy has also filed 64 patents over a career,” says Dr. Kieran on new medical devices and Murphy, an interventional started six companies. He’s neuroradiologist at Toronto grateful to be able to devote Western Hospital who uses two days each week to research, imaging-guided technology to and to be part of a “vibrant, fix fractures, perform biopsies “Without [donors support for the intellectually active and and kill tumours in the spine, for questioning” community at the example. PMCC Innovation Committee] we PMCC. Dr. Kieran Murphy Medical professionals such “We’re not just here to do a received the Leaders as Dr. Murphy can take wouldn’t be at this stage; it was a job, but to change how the job in Innovation Award precautions, including wearing very, very important step for us.” is done,” says Dr. Murphy, who from the Society lead shields and lead-lined hopes the premedication anti- of Interventional glasses, and they sport badges Dr. Kieran Murphy, oxidant will be on the market Radiology. that monitor their radiation Interventional Neuroradiologist, Toronto Western Hospital within about a year.

48 Peter Munk Cardiac Centre Winter 2018 49

DM182487_Pg01-51_PMCC_FALL_2017.indd 48 2017-10-06 12:38 PM DM182487_Pg01-51_PMCC_FALL_2017.indd 49 2017-10-06 12:38 PM The ability to run multinational trials is years directing the Mount Sinai to go,” says Dr. Farkouh. It’s build a better wheel,” he says. part of the expertise Cardiovascular Clinical Trials also the first and largest trial of One major study he has in the and experience that Unit in New York City. individualized medicine that the works looks at whether giving cardiologists Dr. Patrick Lawler (left), “When we develop new drugs U.S. National Institutes of Health people with weak immune Dr. Michael Farkouh and new devices, we have the (NIH) has sponsored, he explains. systems a more concentrated and Dr. Jacob Udell ability that most centres in the The beauty of multinational dose of flu vaccine will give bring to the PMCC’s world do not have to go from the trials is not merely the vast scope, them cardio protection. The cardiac clinical work early concept in innovation all but also how the data is actually outcome could be the difference and research. the way to the large clinical trial,” collected and analyzed, says Dr. between life and death for those he says. Patrick Lawler, a cardiologist, with kidney disease, diabetes, That’s partly due to Dr. Boston native and new recruit to cardiovascular disease and Farkouh’s own experience the centre who is a leading expert those with obesity who are running large multinational trials. in preventing atherosclerosis underprotected by the regular While phase one and phase two cardiovascular disease. shot. trials typically involve smaller Dr. Lawler says he was drawn The teams participating in the numbers of people chosen with to the PMCC because the centre’s study have already completed very specific medical parameters focus is unique: a strong interest one flu season. The results will be in mind, multinational trials in developing pragmatic clinical recorded in 2020. examine outcomes in thousands trials that intersect with real- Teamwork and collaboration or even hundreds of thousands of world evidence by pulling data are obviously paramount if large people worldwide. from actual clinical cases. multinational clinical trials Take the FREEDOM Trial, In a pragmatic clinical trial, a are to succeed. And Dr. Udell co-led by Mount Sinai Hospital study could look at how blood in says the centre is working with in New York and the Peter Munk blood banks is used. Are patients nurses, nurse co-ordinators, Chair in Multinational Clinical being given the newest blood or lead administrators and senior Trials. It showed that when the stock that has been shelved leadership at the PMCC and diabetic patients with multivessel the longest? (Think milk growing Toronto General Hospital, as well coronary artery disease have nearer to its expiration date.) as teams across the country and bypass surgery, they live longer Then, when you follow these beyond. and are less likely to experience patients through their electronic “This couldn’t have happened complications than those who health records afterward, what without everyone coming to the undergo angioplasty. are the outcomes? table,” he says. “It’s going to take The Tailored Antiplatelet “These kinds of pragmatic trials work and rolling up our sleeves, Initiation to Lessen Outcomes are trying to make use of the fact but we’re on the precipice of Due to Decreased Clopidogrel that our health-care system is doing something pretty cool that Response After Percutaneous increasingly digital, electronic will open the floodgates for many Coronary Intervention (TAILOR- and connected,” says Dr. Lawler. trials to come.” PCI) study is another large trial “In theory, this should be a more the PMCC is currently co-leading efficient system. The trials should with the Mayo Clinic. It’s meant cost a lot less money and they THE PETER MUNK to determine whether patients should be faster.” CENTRE OF with stents should receive And as the TAILOR-PCI trial EXCELLENCE IN the drug Plavix or another shows, the centre also specializes MULTINATIONAL prescription. in precision medicine that focuses CLINICAL TRIALS Thirty per cent of people are on making medicine more actually unable to metabolize individualized for patients. Plavix. They have a genetic So why leave his full-steam- Leads more than variation in a liver enzyme that ahead career in Boston to come to 10 international prevents it. Ultimately, the drug is the PMCC in Toronto? clinical trials next to useless for them. “You know, I think what I was But what if you could tell – excited about was the spirit of 30,000 through rapid genotyping – who innovation and creativity here. patients is a good candidate for that There’s an environment that standard medication and who encourages scientific risk-taking,” 400 should receive an alternate he says. physicians, scientists and CORONARY HEART DISEASE. 2011 and one of seven Centres medication that’s more effective Dr. Jacob Udell, a cardiologist researchers It doesn’t care if you’re Canadian, of Excellence established by for them? with expertise in women’s health, Finding global solutions American or living in India, the Peter Munk Cardiac Centre The TAILOR-PCI study team diabetes and novel ways to protect 200 Kenya or Spain. Political (PMCC) to transform the way uses genotyping technology – a patients from heart disease, sites boundaries mean nothing to a patients with cardiovascular quick cheek swab – in some of arrived in Toronto from Boston to cardiovascular disease condition that kills an estimated disease are treated around the the 6,000 patients enrolled in in 2012, also at Dr. Farkouh’s 20 countries 3.8 million men and 3.4 million world. the trial to see if genetic testing urging. Dr. Udell says he, too, participating worldwide women globally each year. “We bring innovation and what before prescribing medication was impressed with the Centre The Peter Munk Centre of Excellence in Multinational Clinical Trials is uniquely So why shouldn’t cardiac clinical we call the ‘one-stop shop,’” says after angioplasty leads to better of Excellence when he saw an Also involved in another positioned to study the world trials and research also break Dr. Michael Farkouh, the Peter patient outcomes. So far, the team opportunity to join an emerging 70 trials in: heart failure, geographic barriers? Munk Cardiac Centre Chair in has signed up more than 4,000 group ready to use big data in vascular surgery, adult congenital That’s part of the thinking Multinational Clinical Trials, patients in Canada, the U.S. and Canada and beyond. heart disease, electrophysiology, behind the Peter Munk Centre who came back to Canada in South Korea. “I want to leverage the power cardiac imaging and By Kira Vermond of Excellence in Multinational 2010 after working in the United “It’s about trying to show that of our health information system interventional cardiology. Clinical Trials, launched in States for 20 years, including 10 individualizing care is the way in Canada and the U.S. to try to

50 Peter Munk Cardiac Centre Winter 2018 51

DM182487_Pg01-50_PMCC_FALL_2017.indd 50 2017-10-13 9:42 AM DM182487_Pg01-50_PMCC_FALL_2017.indd 51 2017-10-13 9:42 AM 76205_PMCC_FoundationAd_Pres_Art.qxp 2017-10-11 4:46 PM Page 1

THE HEARTBEAT OF Peter Munk Cardiac Centre INNOVATION by the numbers* $28.8M For 20 years, the Peter Munk Cardiac Centre in research funding has been at the forefront of discovering +163,000 newer and better ways to care for patients outpatient visits with heart disease. The knowledge generated +10,000 here is transforming cardiovascular care across cardiac & vascular procedures the country – and around the globe. 2,400 Accelerating healthcare innovation patients in cardiac Here’s what the future of cardiovascular care looks like: rehabilitation DEVELOPING A DIGITAL DETERMINING THE BEST 160 CARDIOVASCULAR TREATMENTS FOR PATIENTS A P R O V E D B Y Our goal is to improve the lives of three billion people every year by 2025. We are clinical fellows

HEALTH PLATFORM WITH HEART DISEASE & residents from proud to support the Peter Munk Cardiac Centre and committed to lead the way in by partnering with the vector by leading a worldwide clinical around the world delivering innovation. Through clinically relevant technology and a unique blend of institute, we will use artificial research network, we will improve cardiology solutions, we will contribute to building the healthy society that we all intelligence and machine learning our understanding of heart disease 67 envision. to help guide decisions in the clinic, and accelerate the development of funded principal and to advance biomedical research. new treatments. investigators DELIVERING TRAINING FUTURE LEADERS 35 PERSONALIZED MEDICINE by sharing our knowledge, we will

heart transplants 1 . 2 5 " by making treatment decisions based educate the healthcare leaders of on patients’individual genetic makeup, tomorrow from canada and around 34 we will deliver the right treatment, at the globe. mechanical P M C a g z i n e N e x t I s u f u l p a g e = 9 " x 1 4 C U H N - 1 7 0 2 M o n d a y S e p t m b r 2 5 , 0 1 7 7 6 2 0 5 / U n i v e r s t y H a l h N w o k the right time, to every patient. heart pumps

*based on 2016 data Support the heartbeat of innovation: tgwhf.ca/pmcc p u b l i c a t o n i n s e r t o d a a d s i z e c o l u r a d n u m b e r fi l e r a s d d o c k e t / l i n

Discover more www.philips.ca

DM182487_Pg52_PMCC_FALL_2017.indd 52 17-10-06 1:26 PM DM182487_PgIBC_PMCC_FALL_2017.indd 1 17-10-13 9:47 AM Creating a healthier tomorrow.

Rogers is proud to contribute to the Peter Munk Cardiac Centre, and to share its pioneering spirit of pursuing new technology for the betterment of Canadian lives.

“The best is yet to come.”

DM182487_PgOBC_PMCC_FALL_2017.indd 1 17-10-06 1:51 PM