SPRING 2019
NETWORKS CONNECTIONS Libin members focus on excellence in vascular health
LIBIN LIFE | Message from the Director
on cardiovascular health, our researchers are dedicated to the prevention, diagnosis and treatment of patients. Our expertise is well-respected. Libin researchers, including those focused on vascular health, were involved in six of the 18 successful Canadian Institutes of Health Research (CIHR) grants recently awarded to scientists at the Cumming School of Medicine. Altogether, researchers associated with the Institute were awarded more than $4 million in the spring grant cycle. Dr. Todd Anderson, MD, director of the Libin Cardiovascular Institute of Alberta.
T
his edition of Libin Life magazine focuses on one of our key research priorities: vascular health.
These projects range from the development of risk prediction scores for emergency department patients with suspected coronary artery disease to a research project looking at the role of adipose (fat) tissue in earlyonset disease risk in offspring.
Vascular health encompasses everything from the health of arteries and veins to open heart surgery. It’s an important area of focus because vascular disease is responsible for the death of more than 25 per cent of the population from heart attack and stroke.
While we are proud of the research underway at the Libin Institute, we know that patients are the reason behind this work. That’s why we are so pleased with the work of our clinicians, who are responsible for caring for tens of thousands of patients each year.
Ninety per cent of Canadians have at least one risk factor for vascular disease. These include such things as smoking, stress, high cholesterol high blood pressure, diabetes, inactivity and being overweight. The good news is vascular disease is often preventable through healthy lifestyle choices, and one of our Institute’s priorities is to help find ways to prevent these conditions.
We are humbled by the dedication of our members and staff, such as nurse-educator Andrew Mardell, who was recently named a fellow of the Heart Rhythm Society, a prestigious honour. (See story pages 22-23).
Our focus is to enable cardiovascular health through transformative research. Our research in the area of vascular disease brings together researchers from multiple disciplines. From scientists like Dr. Jennifer Thompson, PhD, who is studying the impacts of adverse conditions in the womb on the offspring (see story page 8-9); to clinicians like Dr. Brian Clarke, MD, who recently implanted the first cardioMEMS device in Western Canada (see story page 12-13); to experts on the impact that nutrition and exercise have
We are also extremely proud of our trainees, who make up the next generation of researchers and clinicians. It’s exciting to get a glimpse into their hard work and innovation at the Tine Haworth Cardiovascular Research Day, held in April each year. The quality of their work is exemplary, and I hold out high hopes for a brighter future in cardiovascular health. Finally, we at the Libin Institute are grateful for our community partners. Without you, the critical work underway at the Libin Institute wouldn’t be possible!
Dr. Todd Anderson Director Libin Cardiovascular Institute
Libin Life Libin Life is published by the Libin Cardiovascular Institute, an entity of the University of Calgary and Alberta Health Services (Calgary Zone). The purpose of Libin Life is to share news and information about the Institute’s impact in research, education and patient care. Institute Director Dr. Todd Anderson @Libin Director Institute Deputy Director Dr. Anne Gillis Director of Science Education Dr. Robert Rose, PhD Editor Dawn Smith, Communications Coordinator Editorial Committee Barb Jones, Myrna Linder, Martin Mackasey, Judy Siu, Dawn Smith, Jeannine Turnbull, Dr. Robert Rose, Dr. Turin Chowdhury Contributors Dr. Todd Anderson, Kelly Johnston, Dawn Smith, Steve McFarlane, Martin Mackasey, Cindy Kalenga Design and Layout Dawn Smith Cover & Inside Spread Design UCalgary’s Creative Studio Printer McAra Printing @mcaraprinting Libin Cardiovascular Institute of Alberta University of Calgary HSC G242, 3330 Hospital Drive NW Calgary, Alberta T2N 4N1 Phone 403.210.6271 libin@ucalgary.ca libininstitute.org Twitter @LibinInstitute Facebook @LibinInstituteCV Editorial Inquiries Dawn Smith Communications Coordinator dawn.smith@ucalgary.ca Send comments, requests for magazine copies, digital magazine issue subscriptions or change of mailing address notifications to libin@ucalgary.ca. Please request permission to reproduce any part of this publication. All rights reserved. © 2019 Libin Cardiovascular Institute of Alberta.
Contents Departments:
Education:
3 Awards & accolades
16 Q&A with new education director
4 New recruits
17 Focus on trainees 18 My mentor
Features: 2 Networks and connections: Explaining the vascular system
Research:
14 Timeline of cardiac surgery in Calgary
8 Getting to the root cause
28 Scholarships creating lasting legacy
10 Making imaging tests safer
Care Delivery:
7 Brain in Motion
19 Serendipitous situation 20 Aortic research at the Institute
12 Keeping tabs on health: first cardioMEMS device in Western Canada implanted
24 A novel APPROACH
22 Nurse clinician constantly upgrading skills
Patient resources:
27 Optimizing outcomes: project improving care for heart failure patients
About the Libin Cardiovascular Institute The Libin Cardiovascular Institute is an entity of Alberta Health Services and the University of Calgary. It is made up of 1,500 members, staff, students and clinical trainees that coordinate cardiovascular research and education, along with delivering world-class cardiac care to a population of more than two million people in Southern Alberta, Saskatchewan and Eastern British Columbia.
5 Let food be thy medicine 6 Finding reliable health information online
SPRING 2019
NETWORKS CONNECTIONS
Libin researchers focusing on vascular system page 14
About the cover A healthy vascular system is an impressive system with numerous networks and connections that work together to ensure the body receives what it needs. Lots can go wrong with an unhealthy vascular system: everything from aortic aneurysms to valve issues and plaque build up, a condition that can cause heart attack and stroke. The Libin Institute is committed to reducing the burden of suffering and premature death through transformative research
2
LIBIN LIFE
Networks & connections
Explaining the vascular system By Martin Mackasey, PhD candidate
The vascular system, also known as the circulatory system, is a complex network of vessels that carry blood and lymph, along with nutrients, oxygen, carbon dioxide, hormones, and other factors within the body. In general, arteries carry oxygen-rich blood away from the heart and veins return blood to the heart. As the arteries carry blood to supply the organs, they narrow into smaller and smaller vessels that allow blood to reach almost every cell in the body, supplying nutrients and picking up waste products and carbon dioxide to be processed in the kidneys and liver before returning to the heart. After delivering the necessary nutrients, blood travels through the veins to the heart where it is shuttled through the lungs and resupplied with oxygen in preparation for the next circuit through the body. The lymphatic system is also a key part of the vascular system. The vessels in the lymphatic system help protect and maintain the fluid environment of the body by filtering and draining the fluid in the interstitial area (the area between the cells) away from each region of the body. The vasculature in our body allows the organs to function properly and protects our body from disease.
Sometimes blood vessels can weaken and expand, even to the point of rupture. This is known as an aneurysm.
Vascular disease most often impacts blood flow by blocking or weakening blood vessels or by damaging the valves that are found in veins.
A decrease or block in blood flow can damage organs and other body structures. For example, blockage of blood vessels supplying the heart causes rapid death of the muscle from lack of oxygen. This is known commonly as a heart attack. Scientists hope to learn effective methods for preventing vascular diseases such as atherosclerosis.
Hardening or narrowing of blood vessels due to plaque buildup is known as atherosclerosis.
Atherosclerosis is a complex disease that results from smoking, diabetes, cholesterol and high blood pressure.
However, controlling these risk factors is not enough to prevent this potentially life-threatening disease. Research is critical for our understanding of this and other related vascular diseases. Martin Mackasey is a doctoral candidate at the Cumming School of Medicine. He is training in the lab of Dr. Robert Rose, PhD, whose research focuses on the cellular and molecular basis for cardiac arrythmias (abnormal heartbeats) that occur due to genetic mutations or in the setting of common forms of heart disease such as hypertension, heart failure and diabetes.
3
LIBIN LIFE
Congratulations! Dr. Kara Nerenberg, MD, was awarded a Women’s Heart and Brain Mid-Career Chair by the Heart and Stroke Foundation. We can’t wait to follow her research program focusing on the heart and brain health of postpartum Canadian women.
Dr. Matt James, MD, PhD, received an Emerging Research Leader Killam Award. James is a kidney doctor and research co-director for the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH).
Dr. Elena Di Martino, PhD, was appointed UCalgary’s Centre for Bioengineering Research and Education Director.
Dr. Amy Metcalfe, MD, and Dr. Tolulope Sajobi, PhD, were each amongst Avenue Magazine’s Top 40 Under 40 recipients!
Dr. Anne Gillis, MD, received an Achievement Award from the Canadian Cardiovascular Society for serving patients and conducting research in electrophysiology.
Libin researchers received $22M in research revenue in fiscal year 20172018. This includes millions in extremely competitive Canadian Institutes for Health Research grants.
Dr. Brenda Hemmelgarn, MD, PhD, received the Outstanding Achievement in Health Innovation ASTech award for her medical advancements in treating chronic kidney disease.
Dr. Sonia Butalia, MD, received a New Investigator Award from Diabetes Canada for her research focused on tools and strategies to improve diabetes care and other cardiovascular risk factors in the community.
Dr. Robert Sheldon, MD, PhD, received a Lifetime Achievement Award from the Arrhythmia Alliance for his work helping syncope sufferers.
Dr. Debra Isaac, MD, received a prestigious International Career Achievement Arch Award from UCalgary’s Alumni Association for her work in improving cardiac care in Guyana through the Guyana Program to Advance Cardiac Care (GPACC).
Dr. Marcello Tonelli, MD, was named a Clarivate Highly Cited Researcher for 2018. Only the top 1 per cent of researchers globally make this list.
4
LIBIN LIFE
Growing team
Get to know the Libin Institute’s new recruits David Barril Dr. David Barril, PhD, recently joined the Libin Institute. An assistant professor in the Faculty of Kinesiology, Barril was born in Alicante, Spain and earned his PhD in cardiovascular physiology at the University of Avignon in France. Barril’s research interests lie in how blood volume is impacted by various cardiovascular conditions. His interest in this area was piqued because the biological processes are largely unexplored, despite the fact that blood volume is an integral part of the cardiovascular system, and there are major clinical applications for patients with cardiovascular and kidney disease. Barril is excited by the fact that there are other researchers at the Libin Institute with interest in the area, and he is looking forward to learning from other experienced researchers in related fields. Outside of work, Barril enjoys spending time with family, riding his bike in the mountains and searching for stimulating books.
Gavin McCormack Dr. Gavin McCormack, PhD, is an associate professor in the Department of Community Health Sciences at the Cumming School of Medicine. He earned his masters of science in sports science at Edith Cowan University in Western Australia and his doctorate in public health at the University of Western Australia. He grew up in Perth, Australia and moved to Calgary in 2007. His research interest is the relationship between urban environments and health with a focus on physical activity and weight in adult populations. McCormack’s interest in this area was honed as a PhD candidate, when he was exposed to the concepts of population health and populationlevel interventions. That’s when his interest evolved from exercise for fitness to physical activity for health. McCormack uses Geographical Information Systems (GIS) and Global Positioning System (GPS) device data, which tend to be large and complex, in his research. McCormack is also a member of the O’Brien Institute for Public Health. In his spare time, he enjoys weight lifting and is a motorcycle fan. His current ride is a red Ducati Super Sport.
5
LIBIN LIFE
Let food be thy medicine
Eat healthy for optimum health By Dawn Smith
D
iet plays a huge role in risk of death. In fact, according to Dr. Norman Campbell, MD, about 50,000 Canadians died in 2017 from dietary risks, leading all preventable risks of death. Nearly all of those deaths were from cardiovascular problems, such as heart attack and stroke, but a bad diet can also be linked to other chronic diseases such as cancer, says Campbell, an international expert in high blood pressure and nutrition who sits on the World Health Organization’s Expert Advisory Group on Nutrition. One of the reasons behind the problem is that many Canadians think they have a healthy diet. In fact most diets are based largely on unhealthy processed foods high in sodium, sugar, calories, and trans and saturated fats and deficient in nuts, seeds, legumes, whole grains, fruits and vegetables. So how can the average Canadian improve their diet? Campbell says it isn’t difficult, and offers the following tips to get started:
•
Focus on eating fresh or fresh-frozen fruits and vegetables. These foods should make up the bulk of your diet.
•
Cut out saturated fats, transfats, simple carbohydrates and sodium. Avoiding processed foods and eating out at restaurants will make this easier. Don’t forget beverages, like soda and fruit juices, may be extremely high in sugar and are best avoided.
•
Get rid of dietary deficiencies by eating low fat dairy products, lean meats, legumes, nuts, seeds and fruits and vegetables. The Mediterranean diet is an example of a healthy diet.
•
Watch out for condiments, they often contain lots of sugar, saturated fats and sodium and can be full of empty calories.
•
Stop going on fad diets. Everyone is looking for a quick fix, but eating a diet high in fruits and vegetables, along with whole grains, lean proteins and nuts and seeds is your best bet for long-term health.
Campbell is also known for his advocacy work at the national level. He was a consultant advising the federal government on the new Canada Food Guide and is a proponent of stricter food policies as a way to improve the health of all Canadians. If you want to help Campbell and others enable better nutrition, consider signing the Calgary Statement, which can be found on change.org. Simply search for “enact food policies to curb chornic disease and health inequity for all Canadians” on the site. The statement calls on the Canadian government to adopt science-based policies to enable healthy eating; make nutritious food and beverages accessible and affordable to all; and eliminate marketing of unhealthy products to kids. It also calls for warning labels on the front of unhealthy products, a tax on unhealthy foods and for government to minimize food industry influence on government policy. Campbell is a member of both the Libin Cardiovascular Institute and the O’Brien Institute for Public Health.
6
LIBIN LIFE
Back at it It’s a jungle out there Finding reliable health information online
Exercise speeds post-surgery healing
Wondering how to get back to your daily activities after a heart surgery or procedure?
n today’s digital world, we are overloaded with news, data and opinions. This glut of information covers everything from science to parenting to health advice, and, sadly, much of it is inaccurate or even false.
Common Red flags
Libin clinical-scientist Dr. Aaron Phillips, PhD, says exercise is critical in recovering quickly after many heart interventions, helping patients to get back to their normal activities after a procedure.
Misinformation can be used to sell products or push an agenda, and we often make the problem worse by failing to check the validity of the information we are passing along on social media or in conversations with friends. This can cost us money and even put our health at risk. But the good news is, a few checks and balances is all that is needed to navigate through the jungle of health misinformation available to us. Read on to learn how.
•
There is a product or service being offered to purchase.
•
There are extraordinary claims for easy solutions to complex problems (such as weight loss).
“The benefits of exercise permeate all aspects of life,” he says. “Not only do the blood vessels and arteries get healthier, but the heart muscle itself improves in its function and structure.”
By Dr. Turin Chowdhury, PhD
I
Advertisers can spread misinformation as part of a marketing campaign for health products. Knowing the following red flags can help alert you to the possibility of an advertising campaign:
•
Meaningless jargon, such as ‘natural,’ ‘medical,’ ‘secret,’ ‘detoxify’ and ‘scientifically proven,’ can be giveaways.
•
Celebrity endorsements, testimonials from “average citizens” and beforeand-after stories are used.
•
The phrase “satisfaction guaranteed or your money back” is part of the pitch.
Check your source
Relying on health information from reputable health sources, such as My Health Alberta or WebMD, reduces the risk of falling prey to misinformation. By checking the source of a questionable social media post, blog entry, or an online article, we may be better able to distinguish between the truth and misinformation and avoid falling prey to bogus scientific studies, personal opinion and product promotion.
Find a trusted source
I choose WebMD and Medline Plus because those sites are reliable sources that cover a variety of topics. If you aren’t sure where to find reliable information, team up with people who are knowledgeable about the particular information you seek. A trusted health-care provider is your best bet.
In addition, exercise increases mental wellbeing and reduces the inflammatory response that can cause problems after surgery. The type of exercise recommended might surprise you. According to Phillips, research shows that high intensity interval training may be beneficial. However, he warns patients to check with their physician before embarking on any exercise program. Aaron Phillips is a clinical exercise physiologist and an assistant professor in the Cumming School of Medicine’s departments of Physiology and Pharmacology and Clinical Neurosciences. He is a member of both the Hotchkiss Brain and Libin institutes.
7
LIBIN LIFE
Clinic caters to cardiovascular patients C-Era clinic started in 1999 and offers non-invasive outpatient cardiometabolic risk assessment, diagnostics and intervention. The clinic sees 1,000 new patients each month, at times within days of a visit to the emergency room. Patients are also referred by family physicians.
Brain in Motion
Researchers investigate link between exercise and cardiovascular health
I
t’s no secret that exercise is good for you. It cuts down on stress, reduces the risk of chronic diseases such as diabetes and heart disease and helps you sleep. From 2011-2016, UCalgary researchers examined the benefits of exercise at a deeper level with Brain in Motion I, a study that showed a significant relationship between fitness, regulation of the vascular system and cognition in older adults. Led by Dr. Marc Poulin, PhD, the study followed 300 patients for 18 months, during which time they exercised three times a day. An interdisciplinary team measured their fitness, vascular stiffness, and cognitive skills including memory and thinking skills to try to discover how exercise can protect cognition. The Canadian Institutes of Health Researchfunded study had some interesting results, and researchers are embarking on Brain in Motion II. That study will follow older adults at increased risk of dementia, with the goal of understanding whether and how exercise improves brain blood flow and cognition. “The power of exercise is huge,” says Poulin. “It can help modify the course of diseases.”
Brain in Motion II will also look at barriers to exercise and the promotion of healthy exercise behaviour. The study involves numerous members of the Libin Institute, and other experts, including a geneticist, geriatric specialist, psychologist, statistician, interventional cardiologist, exercise physiologist and imaging specialists.
Maureen Thomas, administration manager for C-Era, says the team of 11 specialist physicians, along with staff, complete thorough assessments of their patients, who have often experienced symptoms that indicate a possible heart problem, such as shortness of breath, chest pain and abnormal heart rhythms. “We get the ball rolling,” she says, explaining the clinic assesses patient risk through a number of diagnostic tests both on and offsite.
Researchers are recruiting volunteers for the study. If you are between 50 and 80 years old and have one of the following: hypertension, diabetes mellitus, obesity, high cholesterol, current smoker, history of coronary artery disease, a parent or sibling diagnosed with dementia, you are eligible to take part in Brain in Motion II.
If the clinic, which is integrated into the health-care system, discovers a problem is heart related, the team either takes on patient care or directs the patient to other specialists to manage the problem. The team also aggressively manages risk factors, such as hypertension and diabetes.
To be involved in this important study, call 403210-7315 or email the study’s coordinators at bimstudy@ucalgary.ca. Participants will take part in a six-month aerobic exercise or stretchand-strength program.
The clinic reduces wait times for follow up tests for patients and reduces the burden on emergency departments by expediting diagnosis, care and treatments.
Poulin is a member of the Libin Cardiovascular Institute, the O’Brien Institute for Public Health and the Hotchkiss Brain Institute.
“The waiting is sometimes the hardest part for patients,” says Thomas. “The faster we go, the less likely our patients will be to end up back in the emergency room.”
8
LIBIN LIFE
Getting to the root cause
Researcher studies impact of fetal development on health
9
LIBIN LIFE
D
octor Jennifer Thompson, PhD, an assistant professor in UCalgary’s Cumming School of Medicine, wants to uncover the developmental links to cardiovascular disease. The basic scientist’s lab within the Libin Cardiovascular Institute of Alberta investigates the long-term effects of individuals subjected to suboptimal or adverse conditions in the womb, such as gestational diabetes or maternal obesity. Her overall goal is to decrease the lifetime cardiovascular burden in babies born at risk, who are more likely to develop cardiovascular risk factors throughout their lifetime, starting in childhood, as several human studies reveal.
the blood, triggering obesity-associated problems such as insulin resistance and atherosclerosis, a condition in which plaque builds up in the arteries. “The residual population of fat cell progenitors serves an important protective role” she said. “This population is likely developmentally determined, but we don’t yet know how adverse conditions in the womb impact this population.” Clarifying the developmental determinants of cardiovascular disease risk may help researchers and doctors better predict risk for individuals and populations. It may also help in finding the best
approaches to optimize long-term outcomes for babies born vulnerable to these cardiovascular risks. Thompson’s work is critical, given the rise of pediatric obesity, insulin resistance and high blood pressure in children. “The good news is that if we can understand this, we can prevent it,” says Thompson, who is a member of both the Libin Cardiovascular Institute of Alberta and the Alberta Children’s Hospital Research Institute. Follow Dr. Thompson’s work at jenniferthompsonlab.com
Thompson explains while chronic diseases, such as cardiovascular disease, were traditionally thought to be due to a combination of genetics and poor lifestyle choices, researchers now know that the fetal environment plays a significant role in determining long-term health and risk for chronic disease. Her ongoing work involves using mouse models to identify the developmental disruptions that make offspring more vulnerable to cardiovascular disease in later life. She is hoping to discover the molecular basis of this developmental programming. Thompson recently received a prestigious $554,625 Canadian Institutes for Health Research grant to study the role of adipose tissue, connective tissue that is responsible for storing energy in the form of fat, in early-onset disease risk. Thompson explains the offspring of moms who have gestational diabetes are at a greater risk of developing early-onset cardiovascular disease, but the reason isn’t clear. She theorizes the development of fat cells is accelerated in fetuses of diabetic mothers, leading to a premature depletion in fat cell progenitors, which have the job of buffering excess energy intake. When fat cell progenitors (the precursors of fat cells) are depleted, lipids spill over into
(Left) Dr. Jennifer Thompson, PhD, works with summer student Victoria Palmgren, in her lab at UCalgary’s Foothills Campus. (Above) Thompson’s research focuses on how the fetal environment impacts future cardiovascular health of the offspring. The goal is to impact the lifelong health of babies born vulnerable to cardiovascular risks. Photos by Dawn Smith.
10
LIBIN LIFE
Dr. Dan Muruve, MD, and his team, including postdoctoral fellow Arthur Lau, have developed effective protocols to minimize the risk of acute kidney injury due to intravascular contrast dyes used in diagnostic tests. Photo by the University of Calgary.
Making imaging tests safer Team discovers how to protect kidneys By Kelly Johnston, Cumming School of Medicine & Karen Thomas, Kidney Foundation of Canada
E
very year millions of people undergo medical tests and procedures, such as coronary angiography, which use intravascular contrast dyes. “For the majority of patients, these are safe and necessary procedures. However, about eight per cent of those people experience the complication of acute kidney injury (AKI),” says Dr. Dan Muruve, MD, a kidney specialist and member of the Snyder Institute for Chronic Diseases at the Cumming School of Medicine (CSM).
“My kidney function was at 13 per cent when I was diagnosed with acute kidney injury. I easily could have ended up on dialysis,” says Sam Hannon, who underwent two angioplasty procedures after having a heart attack. “Anything that can be done to make all procedures safer for patients is great news. This research is vital.” “People like Sam, who require complex procedures with large contrast dye volumes, or those with pre-existing
diabetes or chronic kidney disease, have a much higher risk of acute kidney injury following these procedures,” says Dr. Matthew James, MD, PhD, also a kidney specialist and a member of the CSM’s Libin Cardiovascular Institute of Alberta and the O’Brien Institute for Public Health. “We have effective protocols to minimize that risk, but occasionally, in some high risk patients, these measures are insufficient to completely prevent kidney damage. This research has
11
LIBIN LIFE
shown how the kidney responds to the contrast dye, and reveals new ways we could better protect the kidneys.” James and Muruve are collaborators on a Canadian Institutes of Health Research (CIHR) team focused on inflammation and kidney disease. In a study published in the Journal of Clinical Investigation, the team shows for the first time how contrast dye injures the kidney. Using specialized high-powered microscopes the scientists were able to map out in real time the dye’s progression through the kidney. The study, using mice models, showed that in a fully hydrated kidney the dye flushes through, but in a kidney with low hydration the kidney absorbs the dye causing inflammation that can lead to serious damage. The new knowledge from this study is already translating to work with people. “We did a small study testing human urine after contrast dye exposure. We saw the same markers in people as we do in mice. These results can help us add to the steps we currently emphasize to reduce the amount of contrast dye used and to hydrate the patient,” says James. “Despite this, some patients with kidney disease currently avoid these medical tests because of the concern about possible injury to their kidneys. This research could help make these tests even safer for them.” The research team is already working on a therapeutic intervention to help those patients who cannot be hydrated easily. “For some patients, with weak hearts, extra fluids are not recommended,” says Muruve. “Through this research we’ve discovered a drug that stops the kidney from absorbing the dye to prevent possible injury. We’ve tested a medication that is showing promising results.” Muruve has since founded a spinoff company to design new medications for AKI. This research is supported by the CIHR and The Kidney Foundation of Canada. “These findings are a great step forward for people living with kidney
Dr. Matthew James, MD, PhD, a kidney specialist, talks with patient Sam Hannon, who underwent two angioplasty procedures after having a heart attack, and his wife Myrna Hannon. Photo by the University of Calgary. failure caused by injury,” says Elisabeth Fowler, national director of research, he Kidney Foundation of Canada. “Our goal in funding research is to work towards finding a cure, and to help translate fundamental discoveries from the lab bench into clinics and hospitals to ease the burden of kidney disease. We look forward to upcoming results of this promising work.” “This study is important because it increases our understanding of how we might intervene to prevent acute renal injury or interrupt the progression of acute kidney injury to chronic kidney disease thereby reducing the burden of kidney disease among Canadians,” says Dr. Norman Rosenblum, MD, scientific director of the CIHR Institute of Nutrition, Metabolism and Diabetes. “As a practicing nephrologist, I look forward to learning more about how this research will be applied in clinical settings.” Muruve is a professor in the Department of Medicine and member of the Snyder
Institute for Chronic Diseases at the Cumming School of Medicine. He is a Canada Research Chair in Inflammation, Personalized Medicine and Kidney Disease, and Medical Director of Alberta Kidney Care (SAB) at Alberta Health Services. James is an associate professor in the departments of Medicine and Community Health Sciences and a member of the Libin Cardiovascular Institute of Alberta and the O’Brien Institute of Public Health at the Cumming School of Medicine. He is a CIHR New Investigator, and supported by a CIHR Foundation Award.
“This research could help make these tests even safer for them.” – Dr. Matthew James
12
LIBIN LIFE
Keeping tabs on health Calgarian first in Western Canada to receive heart failure monitoring device By Dawn Smith
M
ichelle Kotelko’s life looked as promising as any woman’s in her late 20s. She loved her job as an elementary school teacher, enjoyed a passion for singing and choral directing and had recently married Keith, the man of her dreams. But unbeknownst to her, there was something very wrong with her heart. Kotelko was born with Shone’s complex, a rare heart defect that affected the left side of her heart. She remembers having several surgeries as a child, starting at age five, but assumed the defect had been fixed. So when Kotelko and her new husband began having exams in preparation for starting a family, they were shocked when heart specialists informed her she needed surgery to replace her mitral valve. The operation took place on September 2015, but it wasn’t a routine procedure. When the surgeon opened her up, they were shocked at how small the left side of her heart was. They also discovered a smaller than expected valve and an hourglass shaped aorta. The surgeon was able to complete the operation, but Kotelko, then 31, never really recovered from it. Following the surgery, she suffered from shortness of breath, pain when she moved, abdominal bloating and a debilitating feeling of pressure and pain in her head and face. “I couldn’t even walk around the block without being short of breath,” said Kotelko, noting testing in 2017 revealed a complication from her surgery—one of her coronary arteries had been obstructed.
Michelle Kotelko poses with heart failure specialist, Dr. Brian Clarke, MD, in a clinic at the Foothills Medical Centre. Kotelko, a heart failure patient, was the first to have a CardioMEMS device implanted. The device monitors fluid pressures to help manage heart failure. Photo by Dawn Smith. Kotelko, now 34, suffered for three years before she was referred to Dr. Brian Clarke, MD, a heart failure specialist and member of the Libin Cardiovascular Institute.
people of all ages, ultimately results in fluid retention, or congestion, which causes shortness of breath, bloating, swelling and fatigue.
During an angiogram, Clarke diagnosed the young woman with heart failure, a chronic condition in which the heart doesn’t pump blood efficiently.
“We were petrified and felt so helpless,” said Kotelko, explaining simply hearing the words “heart failure” made them feel her condition was a death sentence.
Heart failure can have many causes and result in a stiff heart or weakened heart muscle. The condition, which can affect
Although Kotelko’s condition improved after Clarke started her on medication that helped get rid of excess fluid, she had to be
13
LIBIN LIFE
monitored closely. Like most heart failure patients, this required frequent clinic visits, bloodwork and medication changes. As Clarke explains, managing heart failure can be complex for some people because congestion fluctuates and medical therapy has to be individualized. The kidneys must also be watched closely as they are often impacted. Heart failure hospitalizations can cost up to $1,800 per day with the average patient staying in care for approximately 10 days. Worse yet, hospital stays are closely linked with poor longer term outcomes for patients. In 2011, a new technology was introduced to help manage some patients with difficult to control heart failure and previous hospitalizations. CardioMEMS is a wireless sensor—just millimetres in size—that measures pressure in the lungs (which reflects the level of congestion) in real time. The devices are implanted in the pulmonary artery through a standard procedure in about 30 minutes. Physicians receive daily reports, which allows them to observe changes in pressures and intervene before things get worse. “It takes the guesswork out of it,” says Clarke, explaining the devices have been shown to reduce hospitalizations by up to 50 per cent and improve quality of life. “You can individually tailor a patient’s treatment to them and immediately see the effect of the prescribed treatment. Knowing earlier means we can intervene. We can keep them from that downward spiral and being hospitalized.” After several years of work, Clarke was given the green light to implant several of the CardioMEMS devices as a pilot project to see who would most benefit from the devices in the Canadian health care context. He knew Kotelko was a great candidate. When Clarke approached Kotelko, she jumped at the chance to receive the device. “It was a huge break in the clouds, because we were just coasting,” said Kotelko, who
Kotelko holds a CardioMEMS device, showing the scale of the heart failure monitoring device, which was implanted by Dr. Brian Clarke, MD, in the fall of 2018. was the first patient in Western Canada to receive the device in September 2018.
says Clarke. “It can be a game changer in heart failure management.”
“It has put an end to the perpetual catchup game and made my heart failure far more manageable.”
Clarke has since implanted the device in a second patient, and more patients are scheduled to receive the CardioMEMS device in the coming months.
Within a week of being monitored by the device, Kotelko’s pain went away. Her part in the process is simple: each morning she lies on a special “pillow” for 10 seconds while the device in her heart sends data to her physicians at the Heart Failure Clinic at Foothills Medical Centre. Dr. Clarke is pleased that he is able to better manage Kotelko’s condition. “I have been excited about this technology since it was in its conceptual phase, because as a heart failure doctor, you often wish you had this information readily available in your patients who struggle with persistent symptoms despite what you believe is the best treatment for them,”
“It has put an end to the perpetual catch-up game and made my heart failure far more manageable.” – Michelle Kotelko, patient
14
LIBIN LIFE
History of
cardiac surgery in Calgary
The Libin Cardiovascular Institute of Alberta offers world-class cardiac surgery in Southern Alberta. Our surgical training program is one of the most sought after in Canada. Before 1930, there was no heart specialist in Calgary and few cardiac care options for patients. Bold pioneers in the area paved the way for today’s program.
1963-1964 Dr. Morgan performs heart catherization, circa 1960. Glenbow archives NA-2864-6448
First dedicated full-time heart catheterization room opens at Holy Cross. Doctors insert catheter into artery or vein and thread through to the heart. Used for diagnosis and for treatment (such as angioplasty).
1969 First coronary artery bypass graft surgery at Holy Cross Hospital. Clogged arteries in the heart replaced by veins taken from the patient to allow blood flow.
1988 Cardiac operating room opens at Foothills Medical Centre (FMC) with two surgeons: Dr. Teresa Keiser and Dr. Andrew Maitland jointly perform five to six valve replacement or coronary bypasses each week.
1930 Calgary’s first heart specialist, Dr. EP Scarlett, moves to Calgary bringing the city’s first electrocardiograph machine (ECG).
1957-1962 Drs. Morgan and Miller build cardiac surgery team at Holy Cross Hospital, only site of heart procedures in Southern Alberta.
1960 First open-heart surgery performed by Dr. Miller.
Valve replacement surgery at the Holy Cross Hospital circa 1982. Photo by Chris Thomas
15
LIBIN LIFE
2006 • Cardiac surgery residency training program introduced by Dr. John Burgess. • Ventricular Assist Device program initiated by Drs. Jehangir Appoo and Dr. Debra Isaac. The devices pump blood in heart failure patients. • Dr. Appoo performs first TEVAR (thoracic endovascular aortic repair) — a minimally invasive technique to repair aortic aneurysms.
2011 • Dr. Jehangir Appoo repairs ascending aorta after a tear using new hybrid technique. During surgery a stent is deployed as a way to possible avoid a future operation. • First Transcatheter Aortic Valve Implantation (TAVI) performed to repair aortic valve. Procedure involves inserting an aortic valve through a patient’s own valve via a catheter in the patient’s femoral artery.
2012 A visual representation of an aortic reconstruction
2009 Kryptonite tested by Dr. Paul Fedak. The glue-like substance helps hold the sternum together after open-heart surgery.
Dr. Andrew Maitland performs the first minimally invasive valve repair at FMC. The procedure is done through a a small incision in the side of the chest.
2016 Patch, made of bioactive matrix biomaterial, applied to heart during surgery. Helps speed recovery and cuts down on scarring after heart attack. Patch developed by Dr. Paul Fedak lab.
2018
Dr. Paul Fedak holds a container of Kryptonite. Photo by Bruce Perrault
• Dr. Brian Clarke implants the first cardiomems device for advanced heart failure patients. The device measures pressure in the heart remotely and helps doctors determine when to intervene with patients. • Ten heart surgeons at FMC doing 28-30 surgeries per week.
2019 Drs. William Kent and Daniel Holloway first surgeons in Canada to place a HeartMate 3 left ventricular assist device with minimally invasive techniques.
Today, surgeons at the Libin Cardiovascular Institute continue to lead the way with innovations in treatment, diagnosis and techniques. The future is bright for patients in this area.
16
LIBIN LIFE | New recruits
Mentorship matters
New education director shares his philosophies
D
octor Robert Rose, PhD, is the Libin Institute’s new director of science education. Read on for his philosophy on training the next generation of researchers. How long have you been an educator? I have been a faculty member since 2008, teaching first at Dalhousie University in Halifax and now at the University of Calgary. As a professor, education has always been an essential part of my job. This includes not only formal teaching in graduate, undergraduate and health professions courses, but also supervision and training of graduate students, postdoctoral fellows, undergraduate students and medical students. I also had informal mentoring/education opportunities during my own training. Why is education important to you? I would not be where I am today without the education and mentorship that I received throughout my training. It is an honour and responsibility to carry this forward. Why did you agree to take on this role? So that I could contribute to fostering the success of our trainees. How we mentor our trainees and the opportunities we offer our trainees, directly impacts our research success as an institute. The two go hand- in-hand. My goal in this role is to maintain and enhance our high standards in these domains. What is your education philosophy? My philosophy towards education is to foster independence, originality and critical thinking by providing opportunities. I believe success is enhanced by making learning/training engaging. What does the Institute offer trainees? We have world-renowned scientists that offer a range of outstanding training opportunities for individuals at all levels in fundamental science, clinical science
The Libin’s new director of science education, Dr. Robert Rose, PhD, speaks to a trainee in his lab. Rose is passionate about mentorship. and population science. As an institute we are also very fortunate to have funding to support stipends, travel to conferences and awards to recognize the accomplishments of our trainees. We also have a vibrant seminar series, rounds, our annual Tine Haworth Research Day and named lectureships, all of which enable our members to hear from, and interact with, established experts (local, national and international) on a routine basis. These are invaluable components of our research and education activities. Tell us about a student’s success and how it encouraged others. When my first graduate student got their first paper published I was struck by how
proud and excited that student was. I always remember that moment and recognize how impactful it was for that student and how motivating it was for other members of my research team. It is always highly satisfying to see hard work lead to success. Tell us your views on mentorship. I’ve learned so much from my mentors and that continues to be the case. Having good mentors can make all the difference between success and failure. To learn more about Rose’s work, visit his lab website at www.roselaboratory.com.
17
LIBIN LIFE
Focus
on trainees
Get to know the next generation of researchers Born and raised in Calgary, Berkeley Scott earned a bachelor of science degree at Queen’s University. She is excited to be back in Calgary working on a masters degree in science under the mentorship of exercise physiologist Dr. Aaron Phillips, PhD and imaging specialist Dr. James White, MD. Scott’s research uses cutting-edge cardiac magnetic resonance imaging software to evaluate the cardiovascular health of patients who have suffered a spinal cord injury. The goal of the research is to better understand changes in the heart after spinal cord injury to gain an understanding of why cardiovascular disease is the No. 1 cause of death in this population. Scott hopes to pursue her medical degree with the goal of becoming a cardiologist. She is also keen to continue researching as a clinician-scientist. In her free time, Scott loves to travel. She has already visited 34 countries on six continents.
Tristan Dorey grew up in Toronto and earned a bachelor of science (honours) degree from Dalhousie University in Halifax under the supervision of Dr. Robert Rose, PhD. He followed his mentor to the University of Calgary, where he is now enrolled in a doctoral program. Dorey’s research focuses on the sinoatrial node, the natural pacemaker of the heart, and how it functions during diseases such as hypertension and heart failure. Dorey one day hopes to earn a medical degree so he can be a clinician-scientist who is able to translate his research into the development of new therapeutic options for patients. In his spare time, Dorey loves spending time in the mountains. He hikes and backpacks during the summer and skis and volunteers with the Canadian Ski Patrol during the winter.
Dr. Matthew Lloyd, PhD, who grew up in Kamloops, B.C., earned his doctorate in human physiology at Simon Fraser University. He is a postdoctoral fellow under the supervision of Dr. Satish Raj, MD, a renowned expert in fainting disorders, especially postural tachycardia syndrome (POTS), which can be very debilitating for patients. Lloyd’s research focuses on how the nervous system controls blood pressure and on the disorders that result when something goes wrong in this area. Lloyd is excited about the possibilities to learn from and collaborate with world-class scientists and physicians. His career goal is to continue researching the nervous system control of blood pressure, especially looking at what role the small muscles that surround blood vessels throughout the body have. In his free time, Lloyd loves spending time with his wife and two sons. He is also a pianist and guitarist.
18
LIBIN LIFE
How my mentor inspires me
M
entors make a big difference. Cindy Kalenga, who wants to be a physician-scientist, feels lucky to have such a wonderful mentor in Dr. Sofia Ahmed, MD. Tell us about your education I grew up in Stittsville, Ontario, a suburb of Ottawa and earned a bachelor of science honors degree in biomedical science at York University. I am pursuing my master’s degree in medical science with a focus on women’s cardiovascular health at the University of Calgary. Tell us about your research Dr. Ahmed’s lab focuses on cardiovascular and kidney health. My project investigates how hormonal forms of birth control may affect cardiovascular health in young women. Cardiovascular disease is the leading cause of premature death in women in Canada, but there has been dramatic improvement over the past several decades in all age groups except for young women. This prompted investigation into female-specific risk factors, including hormonal contraceptives. Oral contraceptives, one of the most commonly prescribed medications for premenopausal Canadian women, are associated with an increase in blood pressure. We are evaluating arterial stiffness in women using oral and non-oral hormonal contraceptives with the aim of providing the best possible information to women and their health care providers to allow them to make informed decisions about their health. How is Dr. Ahmed a good mentor? Dr. Ahmed is my biggest cheerleader, regularly challenges me and makes it a priority to celebrate my wins, even the small ones. She understands how to inspire the best in her graduate students by helping them identify their strengths and weaknesses. It is clear that she believes in my potential for greatness and pushes
Dr. Sofia Ahmed, MD, poses with her trainee Cindy Kalenga, who is working on her master’s degree in medical science. me beyond my comfort zone in the best way possible. How has she inspired you? Dr. Ahmed is committed to helping me find success and gratification within research. I can tell that she truly enjoys her work, and this attitude is contagious. Often research can be grind. We spend long hours in the lab and complete many edits of a paper before it’s ready for submission. In moments when I’m unable to see the bigger picture, Dr. Ahmed is able to keep the vision alive. She frequently reminds me of how important my research is and the kind of impact it will make within current literature. This gives me the drive to push through because I know the results are exciting. What lessons have you learned from her? Dr. Ahmed repeatedly emphasizes the importance of integrity within research. She has an outstanding reputation amongst her
peers for being trustworthy and reliable, a trait she wants to instill in me. Secondly, she demonstrates high standards of efficiency and productivity and is constantly modelling the behavior required to be successful as a physician and researcher. Lastly, she frequently expresses the importance of having passion for my work. Being a graduate student is a huge commitment and the only reason I can invest so much time is because I truly love what I’m doing. It has been an exceptional experience working with Dr. Ahmed, and I hope that every graduate student has access to great mentors like her.
“Dr. Ahmed is my biggest cheerleader, regularly challenges me, and makes it a priority to celebrate my wins.” – Cindy Kalenga, masters candidate
19
LIBIN LIFE
Serendipitous situation
Clinic caters to cardiovascular patients
Chance discovery motivates scientist to consider sex and gender in her research
E
early curiosity and love of science blossomed into a fulfilling career for Dr. Elizabeth (Tish) Murphy, PhD, who will be delivering the E.R. Smith Lecture on April 2 during the Libin Institute’s annual Tine Haworth Cardiovascular Research Day. Murphy grew up in a small town in the mountains of Pennsylvania. One of four siblings, Murphy had a keen interest in chemistry as a teenager. That interest grew to include biochemistry after an engaging high school biology class piqued her interest in the subject that was to become her life’s work. In the 1970s, Murphy went to college at the University of Pennsylvania but was bored with the labs she was taking. Rather than dropping out, she spoke to her professor. It turned out to be a fortuitous move for Murphy, who went to work in the lab of her professor’s husband, a researcher studying intracellular signalling in the heart and liver. Murphy embraced the opportunity and soon fell in love with the research. She is thankful for the educators who gave her a chance. “A lot of life in any field is taking opportunities as they come,” she says. In 1980, Murphy earned her doctorate in biochemistry/biophysics at the University of Pennsylvania, focusing on calcium’s role in intracellular signaling within the heart. Murphy took another opportunity while working in that same lab, meeting and getting to know her now-husband. When he moved to North Carolina to take the MD-
PhD program at Duke University, Murphy followed. She completed a postdoctoral fellowship at Duke and taught at the university for several years. In 1984, she was hired as a staff scientist at the National Institutes of Health (NIH), where she has conducted heart research for the past 25 years. She is now senior investigator in the NIH National Heart, Lung and Blood Institute, one of 27 institutes funded by the US government agency. Part of her work involves understanding the role of calcium in a heart attack and looking at drugs to manage this process. Murphy explains there is a cascade of effects during a heart attack that starts when heart cells are denied oxygen, forcing the body to use glycogen for energy. However, breaking down glycogen creates lactic acid, which in turn leads to high concentrations of sodium within the cell. The cells exchange this excess sodium with calcium, causing cell death. Her interest in the sodium-calcium exchange led her lab to an interesting discovery—that there are differences between the way male and female individuals respond to the excess calcium. It all started with a ‘happy accident.’ Murphy explains when she was sent a number of female mouse models along with her normal male models, her lab discovered the males were more damaged during a heart attack than females. This led the lab down a new path that incorporates sex differences.
Dr. Elizabeth Murphy, PhD “We have discovered that estrogen is very protective,” says Murphy, noting her goal is to find drug treatments that will protect the heart from the changes caused by lack of oxygen. Today, Murphy continues to incorporate sex differences in her research and is excited about what the future may hold. “It’s amazing how much more we know than we did,” she said. “Research has its ups and downs There can be a lot of frustrations, but there are incredible eureka moments if you enjoy doing research.” Murphy, who has earned numerous awards for her work, sits on numerous editorial committees and has published more than 220 articles, has some sage advice. “If you have a job that is interesting and fun, that is the greatest thing,” she said. “If you really enjoy it, it isn’t work.”
“A lot of life in any field is taking opportunities as they come.” – Dr. Elizabeth Murphy, PhD
20
LIBIN LIFE
Dr. Paul Fedak, MD, PhD, is involved in a study that examines the stress on the walls of the aorta using cutting-edge 4D-flow imaging technology. The goal of the research project, which involves Libin Institute members with a range of expertise, is to better determine which bicuspid patients need their aortas repaired surgically, to what extent and when. University of Calgary photo.
Promising projects
Aortic research aims to improve patient outcomes
C
ardiac surgeon Dr. Paul Fedak, MD, PhD, has a particular interest in aortic disease in patients with bicuspid aortic valves, the most common congenital abnormality, affecting one in every 100 patients. These patients, who are born with two flaps on their aortic valve rather than the normal three, are more likely to suffer aortic aneurysms, which can lead to fatal tears or ruptures. Despite the risks, treating these patients can be a guessing game as there is no consensus on when to intervene.
Fedak is trying to change that with a multi-centered, collaborative study that examines shear stress on the walls of the aorta using cutting-edge 4D-flow imaging techniques. The National Institutes of Health-supported study also looks at the blood and tissue of the patients who have undergone aortic valve repair. This is all being done with the goal of better determining which patients need their aortas repaired surgically, to what extent and when. Fedak was the senior author of a paper published in the December 2018 edition of
the Journal of Thoracic and Cardiovascular Surgery (JTCVS). The article details the study’s findings that for bicuspid patients, increased wall shear stress is significantly associated with elastic fiber thinning in the aorta. As a result, the tissue’s biomechanics are impaired. Another project Fedak is undertaking with Dr. Steven Greenway, MD, a paediatric cardiologist who is a member of both the Libin Cardiovascular and Alberta Children’s Hospital Research Institute, is looking at a potential biomarker for aortic problems. The study looks at whether molecular tags
21
LIBIN LIFE
that are added to cell-free DNA, which is released into the blood when cells die, can be used as biomarker for aortic injury.
Her lab is involved in a number of studies, including Fedak’s 4D-Flow study, which is examining how blood flow is altered in patients with bicuspid valves.
These tags are added through a process called methylation and often change the activity of the gene and create a genetic “fingerprint” for each tissue. Researchers are looking at whether they can detect a specific methylation pattern unique to the aorta that could be used as a noninvasive tool to predict which patients would benefit most from aorta surgery. “It could be used as a screening tool to determine who needs therapy or surgical intervention and when,” said Fedak of the research, which is an extension of his larger NIH-funded project. “It is pretty exciting technology.” A third project recently published in JTCVS discusses a possible correlation between aortic problems and a commonly used family of antibiotics. Doctors often use quinolone antibiotics as a first-line defense against bacterial infections, but the Fedak lab has shown that quinolones decrease the amount of collagen in the tissues of the aorta, which helps protect the vessel and keep it stable. To learn more about Fedak’s work, visit his lab site online by searching for the Campbell Family Cardiac Research Laboratory at the University of Calgary.
Surgery vs. surveillance The Calgary Thoracic Aortic Program (CTAP) is moving forward with TITAN:SvS (Treatment In Thoracic Aortic aNeurysm: Surgery Vs. Surveillance), a clinical research project focused on the problem of whether or not to operate on moderate-sized aneurysms of the ascending aorta, the upper part of the largest blood vessel in the body. Aneurysms are balloon-like growths that can be congenital or acquired. Patients with aneurysms often aren’t aware of the problem, as they may not have symptoms. However, according to Dr. Jehangir Appoo, MD, a cardiovascular surgeon
The study, a multi-centered collaboration that involves 4D-Flow cardiovascular imaging, much of which is conducted at the Libin Institute’s Stephenson Cardiac Imaging Centre under Director Dr. James White, MD, PhD, has found that the altered blood flow causes strain on the wall of the aorta. Di Martino’s lab examines this tissue, placing it under forces to see if it behaves differently than normal tissue.
Dr. Jehangir Appoo, MD and the co-director of CTAP, a tear or rupture can be very serious, even fatal. Appoo says there is very little scientific By Dawn Smith evidence to support at what diameter the growths should be operated on and how extensive those surgeries should be. “Right now it is a bit of an uneducated guess,” says Appoo. He is hoping the multi-centre study, one of the first of its kind on the ascending aorta, will help shed some light on the problem.
According to Di Martino, while researchers know that the tissue of people with bicuspid aortic valves is different from those with normal (tricuspid) valves, they don’t know whether that difference is congenital or a result of altered mechanics. Her lab is hoping to answer this question. “The idea is to study both the blood flow and the mechanics, to see whether altered blood flow impacts the tissue at the cellular level and biomechanically,” says Di Martino, explaining the ultimate goal of the study is to figure out which patients need surgery for their aneurysms, and how extensive that surgery should be.
TITAN:SvS, a collaboration between the Libin Institute and the University of Ottawa Heart Institute, will follow about 550 patients with known aneurysms for five years, randomizing them to receive medications or surgical interventions. All patients will receive annual imaging exams, which will be uploaded via the Cloud from participating sites and stored at a core-imaging lab at the University of Calgary. “This is very exciting,” said Appoo of the project.
Biomedical engineering Dr. Elena Di Martino, PhD, a UCalgary biomedical engineer, is interested in the possible link between structural and mechanical changes in the aorta and vascular pathology.
Dr. Elena Di Martino, PhD
22
LIBIN LIFE
Striving for the best
Nurse educator passionate about peak performance
A
ndrew Mardell is not one to rest on his laurels. The nurse educator, who has specialized in cardiology at the Foothills Medical Centre since Sept. 11, 2001, was recently named a fellow of the Heart Rhythm Society, an honour few nurses achieve. Mardell, a father of five, also holds national certifications in critical care nursing, electrophysiology (EP), and cardiac device therapy and is a nurse educator through Alberta Health Services (AHS). An early interest in the field of health care and a desire for a career with lots of options led Mardell to study nursing at the University of British Columbia, Okanagan Campus. It was at this time that Mardell became keenly interested in cardiology. After graduating in 2000, Mardell began working in Kelowna gaining experience in cardiology and general medicine. It was
then that he realized he had found his calling in cardiology and moved to the much-larger centre of Calgary to allow more opportunities in this area. “I enjoy the challenge of working with patients with multiple issues, and I really enjoy the fact that patients can often walk out of the cardiac units with little impact on their life,” says Mardell. “You really feel like you are making a difference.” Mardell began his Calgary career in the cardiac intensive care unit of Foothills Medical Centre as a staff registered nurse, but it wasn’t long before he decided to further his education by taking a critical care certification at Mount Royal University. Mardell became interested in EP, a sub-specialty of cardiology that focuses on problems of the heartbeat, and worked at the cardiac device clinic, assisting with implanting and managing heart rhythm devices and in the EP
Andrew Mardell, a nurse with a specialty in electrophysiology, was recently named a fellow of the Heart Rhythm Society, an honour few nurses achieve.
23
LIBIN LIFE
lab, where ablations, a treatment for arrhythmias, are conducted. He also began travelling to clinics around the city checking devices, such as defibrillators, to ensure they worked properly. Today, Mardell still works directly with patients, but he has added clinical nurse educator to his list of duties. In this role he educates other nurses about devices and procedures in the clinics in which he works. He keenly enjoys working in the cutting-edge area, where technology changes rapidly. “It is really interesting,” says Mardell. “I enjoy being in a high-change environment.” Mardell’s workday is varied. Besides his clinical and education work, he is involved in policy development, which takes into consideration all the changes in technology and clinical guidelines. He is also a consultant for new EP labs around Western Canada, giving advice on cost-effectiveness to patient outcomes and service structure. He also works on several innovative projects, such as Carelink Express, which involves setting up remote monitoring stations in smaller centers, like Canmore,
Medicine Hat and Lethbridge, for defibrillators and pacemakers. The monitoring stations allow patients to send information to their specialists without having to travel as far, making them a cost-efficient way of delivering care to patients. Mardell is also the provincial subcommittee chair for EP for Connect Care, the comprehensive, new medical record and management system being adopted by Alberta Health Services. He is also the allied health representative on the Canadian Heart Rhythm Society communication committee. Mardell sees research as critical to improving health care and has been involved in several projects over the years, including ASAP-Too, an ongoing study on atrial appendage occlusion that expanded the criteria for patients needing a device to prevent stroke in atrial fibrillation. “It’s a way to move the chess pieces forward,” he said of research, noting in his field new ideas and innovations are common, and the onus falls on practitioners to keep up with what’s new.
Despite all of his accomplishments in health care, Mardell is quick to praise his co-workers, noting his fellow nurses are knowledgeable and amazing advocates for patients. He adds that the physicians he work with are collaborative, innovative and supportive. “I am so privileged to be part of such a great team of nurses and doctors,” he says. “You feel integral to positive patient outcomes.” In his spare time, Mardell is a firefighter with Rocky View County Fire Services and a private pilot who enjoys getting away from it all with a flight in the Rocky Mountains.
“I really enjoy the fact that patients can often walk out of the cardiac units with little impact on their life,” – Andrew Mardell, RN
24
LIBIN LIFE
A novel APPROACH By Mark Witten
W
hen Dr. Merril Knudtson, MD, launched the APPROACH cardiac registry in 1995, he had a vision to improve care and transform outcomes for Albertans with heart disease. More than two decades later, the registry that tracks vital patient health data continues to deliver on the original vision as new opportunities to advance precision medicine are developed and implemented. APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease) is one of the largest and most comprehensive cardiac registries in the world. Since its launch by Knudtson, a professor in the departments of Medicine and Cardiac Sciences and member of the Libin Cardiovascular Institute of Alberta and O’Brien Institute of Public Health at the Cumming School of Medicine, the registry has gathered information on more than 200,000 patients who have undergone more than 500,000 procedures in the province.
statistics, procedure rates, quality of life information, vital statistics and other data, providing a uniquely longterm view of the patient journey. “APPROACH provides important insights about care for many groups of patients, including the elderly, women and patients with co-morbidities (additional conditions such as diabetes or kidney disease). It has provided information about the outcomes of these groups at a population level that’s not available elsewhere and this knowledge influences clinical practice,” explains Dr. Matthew James, MD, PhD, an associate professor and clinician scientist in the departments of Medicine and Community Health Sciences, and co-director of research for APPROACH since 2013, along with Dr. Stephen Wilton, MD. James and Wilton are both members of the Libin and O’Brien Institutes.
Another 15,000 cardiac procedures performed annually in Alberta are added to the database each year.
Older Albertans were among the first to benefit from the data collection and analysis. Decades ago, elderly Albertans with heart disease were less likely to be offered some heart procedures due to uncertainty about benefits and risks.
APPROACH electronically records key data such as hospital admission
“Before APPROACH data was available, it was assumed we shouldn’t give
aggressive treatment to the elderly. Our early research showed that appropriately selected older people who go for angioplasty or cardiac bypass procedure can do well and have better health outcomes than heart patients of the same age who don’t,” says Wilton, an assistant professor in the departments of Cardiac Sciences and Community Health Sciences. APPROACH researchers also discovered that women in Alberta with heart disease were less likely than men to receive cardiac procedures, and not as likely to be referred to or participate in cardiac rehabilitation programs. “We raised the awareness of this discrepancy by identifying these barriers to treatment for women, such as caregiving responsibilities and low income, and showing access to cardiac procedures and rehab can improve quality of life and increase longevity,” says Wilton. APPROACH data also reveals that patients with acute coronary syndromes (ACS) in rural Alberta are less likely to receive an important heart procedure than patients in cities, despite the increased
25
LIBIN LIFE
risk of dying within 30 days if the procedure wasn’t done. “These findings about disparities in treatment for different groups are important for clinicians and patients, and they can help inform health policy decisions that improve access to appropriate care for all Albertans,” says James. The APPROACH model is so successful that it was selected by the Canadian Institutes of Health Research in 2011 as one of six top achievements in health research and it has been adopted by other provincial health-care systems and at hospital sites in most provinces across Canada. Wilton and James are also spearheading an exciting advance in research with APPROACH. Called clinical decision support, it uses the information collected in APPROACH in real-time to help clinicians make better, more informed and more personalized treatment decisions for individual patients. “This system is an example of a tool to deliver precision medicine. Information captured within APPROACH summarizes the experiences of many previously treated patients, and new tools can process this
information rapidly to predict the risk of an event for a new patient receiving care. This helps inform decisions for each new individual receiving treatment,” says James.
Impacting today’s precision medicine
The APPROACH platform is now being used as a tool to make heart procedures safer by helping clinicians prevent acute kidney injury in patients undergoing an angiogram or angioplasty (procedures to identify narrowing or blockages in arteries supplying blood to the heart and widen narrowed or blocked arteries). Exposure to dye injected during these procedures can lead to acute kidney injury, a common and costly complication for patients and the health system. “The APPROACH system includes tools to warn clinicians when a patient is at risk of acute kidney injury. It then gives guidance specific to each patient on the amount of dye that can be used safely and the desired amount of intravenous fluid that can be used to flush out the dye and lower the risk of kidney injury, tailoring recommendations to each patient’s requirements,” explains James, noting that this cutting-edge project is being implemented across the province.
APPROACH has seen significant changes in the past year with the goal of making the information collected more accessible to our heath-care leaders. The APPROACH team is always looking at ways to better meet patient needs and improve outcomes, and access to data helps leadership understand the results of the care we provide as well as the patient perspective. APPROACH partnered with the Clinical Research Unit (CRU), a team of data management and interpretation experts, at the University of Calgary to help manage data. APPROACH is working to make changes to the way data is formatted to make it easier to use. The hope is to streamline what we do, enhance programs based on wait times, and support proven programs that enhance the lives of patients. The team is excited about the ongoing work and engagement with the upcoming Provincial Electronic Health Record. Being part of the change to how health information is gathered and used in Alberta is inspriing for the team. —Barb Jones, RN, provincial APPROACH manager
Save the date New location!
This year’s annual The Beat Goes On Gala will be held at the Hyatt Regency Downtown on September 21, 2019 and will feature Canadian country music artist Paul Brandt.
Watch for sponsorship opportunities and ticket sales on libininstitute.org
27
LIBIN LIFE
Optimizing outcomes Project focusing on improving care for heart failure patients By Dawn Smith
H
eart failure is a growing problem, with 50,000 new cases diagnosed in Canada each year, according to the Heart and Stroke Foundation. Characterized by fluid retention, the chronic condition is the result of a weakened heart muscle that can no longer pump blood efficiently, resulting in swelling, shortness of breath and exhaustion that often keeps patients from normal activities. (Read a heart faiIure patient’s story on pages 12-13). Heart failure, which is treatable but requires close monitoring by health-care providers, is the second most common reason for hospitalization in Calgary. This condition has a huge impact on the quality of life of patients and is a significant burden on the public health system, costing $2.8 billion per year in Canada. Robert Berney, RN, the manager for Units 71, 72 and the Cardiac Function Clinic at Rockyview General Hospital (RGH), says Alberta Health Services at the zone and provincial levels has flagged heart failure treatment as an area that needs improvement. To that end, a group of dedicated doctors, nurses, quality improvement specialists, analytics specialists and other stakeholders has undertaken the Heart Failure Outcome Improvement project at RGH. “We are looking at interventions that could ultimately decrease the length of stay and readmission rates (at hospitals) for these patients,” says Berney, noting
some of the changes include educating patients on things like diet, how to manage symptoms and the physiology of heart failure; notifying and providing care plans to community health-care providers; and adding information to electronic databases. Berney said future phases of the project will include partnering with emergency departments to find opportunities to streamline and enhance care in emergency rooms, which deal with a number of these patients. The group is also looking at ways of providing hospital level care to heart failure patients in their home, a goal that requires partnership with other experts, such as paramedics and home care providers. “Heart failure patients could really benefit from this kind of intervention,” said Berney. “A lot of them are allowed to decline to the point of hospitalization.” Berney is excited about the future of the Heart Failure Outcome Improvement project and its results to date. “This project has a lot of potential to make a difference
for patients,” he said. “We are seeing successes we haven’t before.” Virginia Meyer, an executive director at RGH and colead of the project, agrees. “This project is important to standardize and improve the care for heart failure patients across the entire care continuum, whether the patient is cared for in hospital, or by their family physician or home care provider in the community or in a continuing care facility,” she says. “Patients and health-care providers will be better able to manage this common condition.”
“We are looking at interventions that could ultimately decrease the length of stay and readmission rates (at hospitals) for these patients.” – Robert Berney, RN
28
LIBIN LIFE
Chantal Rytz, who recently completed her masters in the Cardiovascular and Respiratory Sciences Program, received the 2017 Eldon and Sheila Smith Graduate Scholarship in Cardiovascular Research. The grant is helping her continue her research. Photo courtesy Chantal Rytz.
Scholarships creating lasting legacy By Steve Macfarlane, CSM Fund Development
H
elping others has been a passion for Chantal Rytz for as long the bornand-raised Calgarian can remember.
While working on her undergrad degree in medical biochemistry at UBC Okanagan, she’d spend her summers working in a ‘mobile’ Calgary clinic focused on vulnerable populations, providing access
to health care for seniors, Indigenous people, those in remote areas and the homeless all around the city.
through UCalgary’s Giving Day, created a half-dozen prizes for grad students engaged in cardiovascular research.
“The seniors that kind of fall through the cracks of health care really became my passion,” says Rytz, one of 12 to benefit in 2017 from the generosity of dedicated Libin Institute philanthropists who,
Rytz’s interests in science and athletics were always something she hoped she could merge with her natural appreciation and understanding of the elderly, and she found the perfect fit in research
29
LIBIN LIFE
Giving Day Scholarships available through the Libin Cardiovascular Institute Todd and Karen Anderson Graduate Scholarship •
2017: Simranjit Pattar
•
2018: Berkeley Scott
Kenneth M Stephenson Graduate Scholarship •
2017: Alina Ismaguilova
•
2018: Connor O’Rielly
Alvin Libin Graduate Scholarship
Maryell Urroz, a physician from Nicaragua, works in the Dr. John Tyberg, MD, PhD, lab. She received the 2017 Robert G. Peters Graduate Scholarship in Cardiovascular Research. The money is helping her hone her skills as a clinician-scientist. Photo courtesy Maryell Urroz. with the Cumming School of Medicine through the Masters of Cardiovascular and Respiratory Sciences program. But it was Giving Day 2017 that allowed her to invest even more of herself in the cerebrovascular work she was doing with supervisor Dr. Marc Poulin, PhD, on the multidisciplinary Brain in Motion study. This study examines the effect of aerobic exercise on populations with higher levels of cardiovascular and brain and mental health risk factors. Rytz is assessing biomarker changes associated with oxidative stress, high levels of which are correlated with diabetes, hypertension, metabolic syndrome and cancers. Aerobic exercise, according to her research, brings risk levels down. She is thankful the 2017 Eldon and Sheila Smith Graduate Scholarship in Cardiovascular Research allowed her to invest herself in the research. “That was so instrumental in allowing me to spend more time on it,” says Rytz,
who defended her masters in December 2018 and now works in Poulin’s lab. “I could just dive into research and be completely enthralled by it because I knew I had backing or support from people that believed in what I wanted to do.”
Impact crosses borders
Among the many to get the same encouragement is Maryell Urroz, a physician from Nicaragua who has been able to engage in research after connecting with Drs. Israel Belenkie and John Tyberg, MD, PHD, who are looking to improve medical education in Central America. She received the Robert G Peters Graduate Scholarship in Cardiovascular Research in 2017. Nicaragua has no laboratories, equipment or trained research personnel at any university, eliminating clinician science as an option for students there. Thanks to the scholarship, Urroz is able to work in the Tyberg lab on a specialized understanding of the physiology of the left ventricle for a clearer picture of conditions like diastolic heart failure
•
2017: Cindy Kalenga
•
2018: Simranjit Pattar
Robert G Peters Graduate Scholarship •
2017: Maryell Urroz
•
2018: Dianne Timmins
Anne M Gillis Graduate Scholarship •
2017: Ashna Maredia
•
2018: Hongwei Liu
Eldon and Sheila Smith Graduate Scholarship •
2017: Chantal Rytz
•
2018: Cindy Kalenga
— skills and knowledge she will be able to put to good use in the future. “The skills that I will acquire while I am working in Dr. Tyberg’s laboratory will help me start to introduce research in my country,” says Urroz. “This should be a great benefit in education and health care there.” Giving Day happens each April at the University of Calgary. Gifts up to $2,500 will be eligible to be matched while funds last. Support your passion and make a real difference in our community. Learn more at https://givingday.ucalgary.ca/
libininstitute.org
FSC LOGO
@LibinInstitute @LibinInstituteAB