1Heart Matters - Winter 2012

Heart Matters

Heart MattersWelcome to the sixth issue of Heart Matters. Every few months, you’ll find updates on Schulich Heart Centre innovations, clinical services, education and staff activities. If you would like to receive future issues of Heart Matters via email, please send a request to marie.sanderson@sunnybrook.ca.

Volume 3, Issue 1 | Winter 2012

Sunnybrook Achieves Ontario’s Lowest Transfusion Rate for Elective Heart Bypasses

The Schulich Heart Centre has developed a successful multidisciplinary strategy for greatly reducing the need for blood transfusions in primary elective coronary artery bypass grafting, commonly known as heart bypass surgery that is planned in advance.

“We took it upon ourselves to create a new environment where transfusions would be something that would be a rarity versus something common,” says Dr. Gideon Cohen, cardiac surgeon, Schulich Heart Centre. “By improving communication among the team and developing strict guidelines as to when patients should be transfused, we have seen an incredible improvement in lowering our transfusion rates for heart bypass surgery.”

The centre, together with Sunnybrook’s Blood Conservation Clinic, has closely followed the provincial transfusion benchmarks for elective heart bypass surgery. In recently released rates from the Ontario Nurse Transfusion Coordinators (ONTraC) Program, the Schulich Heart Centre has improved greatly, showing the lowest provincial transfusion rate for this group, with data drawn from 60 consecutive patients in 2011. Sunnybrook has been a participant in the highly successful ONTraC blood conservation program funded by the Ontario Ministry of Health and Long Term Care since its inception in 2002 and currently

has one full-time and one part-time blood

conservation nurse dedicated to this initiative.

Patients are assessed before surgery by the

Blood Conservation Clinic to determine their

hemoglobin level, after which an individualized

plan is developed for patients with low

hemoglobins. Optimization strategies include

having patients increase dietary iron, take iron

supplementation weeks before surgery or

receive medications to treat anemia.

“Blood is a precious and limited resource,”

explains Dr. Yulia Lin, Transfusion Medicine

Specialist at Sunnybrook. “We know that

there are risks, both infectious and non-

infectious, with transfusions. Enhancing pre-

operative blood conservation strategies for

patients before their heart bypass surgery

really decreases the need for transfusions.”

The multidisciplinary team, which includes anaesthesiologists, nurse practitioners,

surgeons, perfusionists a n d s t a f f i n t h e Cardiovascular Intensive Care Unit (CVICU) and D3 Inpa t i en t Un i t , also began to look at techniques within the operating room and catheterization labs.

“We are meticulous in the operating room to ensure that there is considerably less bleeding. We spend extra time with each case to ensure that patients are hemostatic,” explains Dr. Gideon Cohen, adding that Sunnybrook’s “take back” rate in which

patients are returned to the operating room for re-exploration related to bleeding is the lowest in the city.

Sunnybrook’s perfusionists, who operate the heart-lung machine during heart bypass surgery, are an integral part of the team. Perfusionists have a good system of retrieving all the blood within the pump circuit and concentrating the blood for return to the patient, with the goal of decreasing the need for a blood transfusion, improving patient safety and enhancing the outcomes of cardiac surgery.

“This was truly a culture shift where everyone came together to work towards decreasing the amount of bleeding and the need for transfusions, which is ultimately the best thing for our patients,” says Dr. Cohen.

2Heart Matters - Winter 2012

Improving Safety and Patient Comfort in the Cardiovascular Intensive Care Unit

Selected patients in the CVICU are now extubated within approximately four hours following coronary artery bypass grafting (CABG) at Sunnybrook. The success in reducing the time of extubation, which previously was roughly 9 to 11 hours following surgery, to the current standard is the result of strong collaboration between the CVICU team, OR Services, anaesthesia, nursing, respiratory therapy and cardiovascular surgery.

For our patients, the changes are dramatic: greater comfort and improved communication. “It allows a patient to communicate with their nurse earlier so we can meet their needs,” explains Carol McMeeken, registered nurse in the CVICU.

The new initiative began on December 5, 2011 and is being championed by Dr. Edgar Hockmann, anaesthesiologist at Sunnybrook. Dr. Hockman has developed an algorithm and education protocol to guide the new practice. At the start of a case, the OR team assesses whether a patient is a safe candidate for early extubation and this is confirmed at the end of the operation. During the handover of the patient’s information from the OR team to the CVICU staff, early extubation is again discussed. Those patients expected to benefit from a faster track have a sign placed at the bedside.

Breakthrough Treatment Successful for Blocked Arteries

The world’s first clinical trial of a new treatment for patients with blocked coronary arteries has shown the novel approach to be safe with promising success rates.

The study involved 20 patients with a coronary artery completely blocked by plaque, a condition called chronic total occlusion (CTO). Each patient received an injection of an investigational drug called MZ-004, an enzyme that softens the plaque over a 24-hour period so that a traditional angioplasty may be performed by advancing a guide-wire through the otherwise impenetrable blockage, then inserting a stent to re-open the artery and restoring blood flow.

Fifteen subjects, or 75 per cent, were able to successfully undergo angioplasty despite previous failed attempts. Published in the journal Circulation and funded by the Canadian Institutes of Health Research, the findings are poised to change the way patients with blocked arteries are treated throughout the world, with a large multi-site, international clinical trial to begin later this year.

“Due to the traditionally low success rate of angioplasty in patients with completely blocked arteries, many patients turn to bypass surgery or treatment with medications alone,” says Dr. Bradley Strauss, principal

investigator and Chief of Schulich Heart Centre at Sunnybrook, who developed the novel formulation and approach. “This treatment provides patients with the option of receiving angioplasty, rather than having more invasive treatment with bypass surgery or living with pain and discomfort.”

Currently approximately 20 per cent of patients having an angiogram are diagnosed

with chronic total occlusions. Of this number, less than 10 per cent have angioplasty, with approximately 25 per cent receiving bypass surgery and the remaining 65 per cent presumably on medication alone.

“Although not all patients with chronic total occlusions need to have an angioplasty to open up the blockage, those who experience chest pain and have difficulty breathing may be able benefit greatly,” adds Dr. Strauss, also a Professor of Medicine at the University of Toronto and the founder of Matrizyme Pharma Corporation, the company responsible for the development of the drug. “In fact, successful angioplasty can relieve the symptoms almost immediately and significantly improve quality of life.”

For patient Louis Waldman, a 49-year-old police officer and father of five, a successful angioplasty after receiving collagenase in March 2011 had immediate results. “I was feeling tired and worn out and a trip to my family doctor revealed that I had a clogged right artery. After one angioplasty attempt that didn’t work, I found Dr. Strauss,” says Louis Waldman. “My discomfort went away almost immediately after the successful angioplasty. I could breathe and had no chest pains. It’s a vast improvement, I’m pretty much back to normal.”

Echo Lab Continues to Grow

With approximately 9000 patients seen l as t yea r, Sunnyb rook ’s Echocardiography Laboratory (Echo Lab) continues to grow. A seventh technician, Tresa Chittalappilly, has been added to the team which provides 24/7 coverage for the hospital. Seeing patients from 20 to 100 years of age, the lab was re-accredited last year by the Intersocietal Commission for the Accreditation of Echocardiography Laboraties (ICAEL). Sunnybrook’s Echo Lab is one of only three laboratories in Canada to be accredited by the ICAEL.

3Heart Matters - Winter 2012

Pictured are Dr. Robert Maggisano, Mary A. McGrath and John P. McGrath

A special thank you to our generous donors

Seymour Schulich

Dr. Sam Radhakrishnan, Dr. Bradley Strauss, Florence Cooper and Sydney C. Cooper

Sunnybrook Moments in Action

Congratulations to Ashley Soryal, a social

worker on D-3, who has been recognized

for providing outstanding service on D-3.

The recognition is part of the ‘Sunnybrook

Moments’ initiative that promotes

positive experiences between staff and

patients, with a focus on compassion,

communication, consideration and

comfort. Congratulations to Ashley and

to everyone in the Schulich Heart Centre

for making a difference with our patients!

Gordon Homer Yvonne Ip So and Andrew So

Dr. Brian W. Gilbert

Chris Li

Schulich Heart Centre Grand Opening

Sunnybrook held two events in November 2011 to celebrate the opening of the new Schulich Heart Centre facilities. Donors who contributed to the facility were invited to tour

the renovated facilities and were acknowledged for their part in helping to raise money for the Schulich capital campaign. At the same time, a virtual tour for the centre was launched on

sunnybrook.ca. The redevelopment project was featured in the North York Mirror and Town Crier papers.

Pictured are Ashley Soryal, social worker on D-3, and Jackie Hutchinson, Patient

Care Manager on D-3.

4Heart Matters - Winter 2012

A Hearty SuccessBy Eleni Kanavas

On November 23, 2011, the Schulich Heart

Program at Sunnybrook Research Institute

(SRI) held its sixth annual research day.

Researchers, clinician-scientists, staff and

students gathered in Harrison Hall for an event

focused on state-of-the-art cardiovascular

disease management.

Dr. Michael Julius, vice-president of research

at Sunnybrook, welcomed attendees. He was

followed by Dr. Bradley Strauss, chief of the

Schulich Heart Program and senior scientist in

biological sciences at SRI. Both emphasized

the importance of translating discoveries into

the clinic and how this translation is shaping

cardiac care.

“In the last 20 years, we have witnessed

advances like stenting and minimally invasive

catheter-based procedures, and we have

gained a richer understanding of the role

regional, gender and ethnic differences play

in determining access to care,” said Julius.

“These and other advances are the product of

research and the continuing focus of Schulich

Heart Program researchers.”

The day was divided into three sessions:

ca rd iovascu la r imag ing , ou tcomes

assessment and analysis, and new surgical

and interventional methods.

Dr. Jack Tu, a cardiologist and senior

scientist in evaluative clinical sciences,

delivered a keynote lecture on ethnicity and

cardiovascular disease in Ontario. He also

summarized research on global rates of heart

disease and the risk factors associated with

different ethnic groups.

Guest speakers were Dr. Chris Buller from

St. Michael’s Hospital, who spoke about

coronary artery fibromuscular dysplasia;

and Dr. Elliot McVeigh from Johns Hopkins

University School of Medicine, who discussed

advances in magnetic resonance imaging-

guided cardiovascular interventions.

Dr. Graham Wright, director of the Schulich

Heart Research Program, summarized

the work of SRI cardiac researchers. “The

emphasis is on innovation and developing

the future of health care in cardiac disease,”

he said. “This includes the evaluation of new

technologies to ensure that they are being

used appropriately in the health care system.”

Wright and his team are using magnetic

resonance imaging to characterize preclinical

models of heart conditions for use in designing

diagnostic and therapeutic studies. He also

co-leads a Canadian Institutes of Health

Research (CIHR) team that is studying

occlusive vascular disease.

Strauss presented results from a multisite

Phase 1 clinical trial evaluating different dose

levels of collagenase, an enzyme-based

therapy he developed to treat patients with

chronically blocked arteries. In the study,

Strauss used a microcatheter to inject

collagenase into blocked arteries to soften

plaque buildup and allow for stenting—a

procedure in which a small, expandable

stainless steel tube is inserted into an artery

to improve blood flow—the next day. Twenty

male patients participated in the study, which

was a collaboration between Sunnybrook and

St. Michael’s Hospital. Strauss reported a 75%

success rate in crossing and stenting 15 of

the 20 patients.

At the end of the day, Strauss spoke to

the future of the Schulich Heart Research

Program. “We want to enhance and encourage

innovation and commercialization of devices

in all areas in cardiology in a way that will

be useful for patients,” he said. “We need to

continue to do that, and we’re well on our way.”

9th Winter Arrhythmia School a Success

Thank you to all the faculty, delegates,

and industry partners for making the 9th

International Winter Arrhythmia School a

pronounced success.

The 9th International Winter Arrhythmia School

was hosted at the Westin Trillium House, Blue

Mountain, on the weekend of February 10 to

12th, 2012. The program provided a broad

introductory base to cardiac electrophysiology

as well as a range of advanced topics such

as channelopathies, complex ablations,

pharmacology, and many more, delivered by

world-leading experts.

A Telemetry Workshop was introduced for

the first time since the event’s inception. The

workshop provided information about the

indications and pitfalls of electrocardiographic

monitoring. Participants successfully developed

an improved understanding and approach to

telemetric arrhythmia interpretation.

What’s Coming…

Senior Friendly on D-3Sunnybrook’s Senior Friendly initiative ensures

that the hospital is sensitive to the needs of its

aging patient population. In early April 2012,

D-3 will participate in the program that focuses

on instilling a senior-friendly culture, physical

environment and early mobility. Already piloted

in D-2, D-4, C-4 and D-5, the initiative will look

at ensuring that patients have three mobility

activities each day, which may range from

going for a walk with a volunteer or more

simple motions like moving from their bed to

the commode. Stay tuned for more details.

Dr. Jeff Healey from McMaster University pictured with Dr. Eugene Crystal, Director,

Arrhythmia Services, Schulich Heart Centre