2020
ON PACE IN SYNC Libin Institute focuses on rhythm
LIBIN LIFE | Message from the Director
a priority. We are making progress in the area of precision care for autonomic dysfunction and arrhythmias. Research projects like REFINE-ICD and AMIQA (see stories page 16 and 18) are exciting and promise better outcomes for patients. The Libin Institute is entering its 16th year, and I am deeply appreciative of the previous leadership team, led by Dr. Todd Anderson, which stewarded the growth of the Institute for nearly a decade. I am excited about our talented and passionate members who will continue to lead the Institute over the next decade. (Read about them on page 2).
Libin Institute Director Dr. Paul Fedak and naming founder Alvin Libin, O.C.
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espite the growing challenges we face in health care, the future has never been brighter for the Libin Cardiovascular Institute. As the new director of the Libin Institute, it is a unique privilege to lead a worldclass team of scientists, clinicians and educators. Libin Institute members provide a rich depth of expertise across a wide range of disciplines. We are cardiologists, surgeons, bioengineers, molecular scientists, clinical outcomes researchers and advanced imaging specialists working in teams with “big data” analysts and much more. As a team, the Libin Institute is uniquely positioned to achieve its goal of optimal cardiovascular health for all. Our plan for the future includes a more integrated approach to the Institute’s three areas of focus: research, education and clinical care. We will leverage our platforms and people by promoting collaboration, and, in so doing, we will catalyze innovation toward better patient care and value. We are already thinking outside the box in many areas. For example, Calgary is now home to one of the first nursepractitioner led cardiac care units in Canada. (See story page 44).
This model is enhancing the patient experience, which is a priority for us as we always put patients first. Our clinical leaders embrace innovation as a way of improving care for our community, and readily adopt new methods such as advanced pacing procedures during cardiac device implementation. The Libin Institute’s goal of promoting collaboration of our people with our platforms will result in further success. We aim to encourage our data experts, for example, to work with researchers and clinicians to drive new solutions to our health-care challenges. For instance, Dr. James White, MD, PhD, developed an international database, MINICOR, with a focus on collecting population-level clinical outcomes data and linking it to advanced imaging data that will be used to more precisely predict an individual’s cardiovascular risks. This information will ultimately be used to help prevent cardiovascular incidents and to enhance the treatment plans of individual patients. (See story page 12). Using population-level data to predict risk for and treat individuals is a critical part of precision medicine. The Libin Institute has made precision cardiovascular medicine
Our past success and bold vision for the future are not possible without the generous support of the Southern Alberta community. We are grateful for the many partnerships we have established to date. Generous community leaders like Mr. Ken Stephenson, the naming founder of the Stephenson Cardiac Imaging Centre (See story page 46), enable us to innovate and provide world-class care. Thank you Ken! With the ongoing support of our communities, the Libin Institute will continue to model excellence and deliver optimal care to the people of Alberta. We will promote the best practices for our patients while working hard on the 'next' practices that will drive meaningful change. The best is yet to come. Dr. Paul Fedak, MD, PhD Director, Libin Cardiovascular Institute
About the 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 care to a population of more than two million people. Its clinical mandate allows for collaboration between disciplines that will ultimately enhance patient care while decreasing health care costs. Together, its members are creating a better model for better care.
Libin Life
Contents
Departments
Education
2 Meet the leadership team
28 Q&A with education director
4 New members
30 Rising Star: Trainee profile
34 Awards & Accolades
32 Nurturing Talent: Amazing mentor
Features
Research
6 Understanding arrhythmias
12 Registry launching internationally
7 Understanding dysautonomia
14 Microscope offers unique perspective
8 She's got heart
16 Q&A with research director
10 Keeping the beat
17 Study examines value of implantable cardiac devices in preventing cardiac arrest
22 A comprehensive approach 44 Donor Profile: Ken Stephenson
18 Study seeks to increase follow up appointments for heart attack patients
Care Delivery
20 World-class researchers tackle mysterious condition
36 Drug offers hope
24 Researcher focuses on spinal cord patients
38 Addressing mental health
26 Cell discovered that can heal hearts
40 Innovative surgical techniques 42 Nurse practitioners take on challenge
2020
ON PACE IN SYNC Libin Institute focuses on rhythm
About the cover Researchers and clinicians at the Libin Cardiovascular Institute are working to understand and treat heart rhythm problems and dysautonomias. By working in sync in a data-rich environment, the Institute's diverse members are on pace to enhance patient care through precision medicine techniques, which individualize treatments for specific patients. The future is sound for the Libin Cardiovascular Institute.
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. Paul Fedak, MD, PhD Editor Dawn Smith Contributors Dawn Smith, Kelly Johnston, Dr. Paul Fedak, Trevor Bacque, Britton Ledingham, Steve Macfarlane, Kate Bourne, Dr. Hailey Jansen Design and Layout Dawn Smith Cover & Inside Spread Design West Village Marketing 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 @LibinInstituteAB 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 ©2020 Libin Cardiovascular Institute.
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Fresh perspective New leadership team to guide Libin Cardiovascular Institute Dr. Paul Fedak took over as director of the Libin Cardiovascular Institute in August 2019. He is a cardiac surgeon, researcher and educator, internationally recognized for his commitment to new surgical therapies for patients with advanced heart disease. An international speaker, journal editor and multiple-award-winning surgeon and researcher, Fedak was recruited to the University of Calgary as a surgeon-scientist. He is the director of the Marlene and Don Campbell Family Cardiac Research Laboratory at the Cumming School of Medicine (CSM) with a research interest in developing novel ways to treat cardiovascular disease. He has more than 150 peer-reviewed manuscripts, numerous published book chapters and over 10,000 citations of his work.
Director
Dr. Paul Fedak, MD, PhD
In his role, Dr. Fedak is responsible for realizing the Institute’s vision of precision cardiovascular health, internationally recognized and funded research, and multidisciplinary educational programs that attract quality learners. By promoting integration of the state-of-the-art enabling platforms within the Libin Cardiovascular Institute with clinical operations, he hopes to improve value and patient-centered care.
Physician and clinical investigator Dr. Nowell Fine is taking on the Libin Cardiovascular Institute’s newly created role of clinical director. He is an assistant clinical professor and the director of Calgary’s Echocardiography Laboratory and the Core Echocardiography Laboratory at the CSM. Fine is also a busy cardiologist who specializes in heart failure and echocardiography with a particular interest in infiltrative cardiomyopathies, a group of diseases characterized by abnormal substances, such as proteins, being deposited in the heart tissues. He is also interested in developing innovative ways to use echocardiography and other forms of cardiac imaging to guide clinical decision making. Fine has published more than 60 journal articles. He is involved in national and international medical societies focusing on heart failure and cardiac imaging.
Clinical Director Dr. Nowell Fine, MD
Fine views his new role as an opportunity to promote the world-class health care and academic programs provided by members of the Libin Institute. He also hopes to foster mentorship opportunities and collaborations within the institute to enhance research.
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Assistant professor Dr. Jennifer Thompson is the Libin Cardiovascular Institute’s new education director. Her research interests lie in studying the long-term effects on the vascular system of individuals subjected to suboptimal or adverse conditions in the womb. Her goal is to one day identify biomarkers to predict the increased risk of cardiovascular disease and diabetes in individuals whose womb environment was altered, which will provide patients and their doctors with important information for their health. Thompson’s ongoing work has uncovered a novel role for fat tissue stems in the programming of cardiovascular disease risk factors in offspring exposed to maternal diabetes while they are in the womb.
Education Director
Passionate about mentorship and providing a well-rounded education to trainees, Thompson hopes to increase student engagement within the Institute. She is excited to see Libin trainees take on leadership roles and build networks with their peers.
Dr. Jennifer Thompson, PhD
Professor Dr. Robert Rose is the Libin Institute’s new research director. Rose’s basic and translational research focuses on the study of cardiac arrhythmia, with a particular interest on dysfunction and disease of the sinus node, the heart’s natural pacemaker. He is also interested in arrhythmias in the atria of the heart, such as atrial fibrillation, a common condition in patients with high blood pressure, diabetes and heart disease. His work in this area is focused on understanding the role of natriuretic peptides, a family of naturally occurring hormones that have protective functions in cardiac tissue, and examining how they can be synthetically engineered to treat heart arrhythmias and heart disease.
Research Director Dr. Robert Rose, PhD
In his new role, Rose hopes to better understand the needs of Libin researchers to enable their success and productivity to continue to increase. He would like to see the Institute recognized as a world class centre for cardiovascular research.
A certified facilitator and change management professional, Dr. Lisa Petermann is the Libin Institute’s operations director. She has more than 15 years of experience in the health-care sector, working with organizations such as the Canadian Cancer Society, the Canadian Institutes of Health Research and Alberta Health Services. Her area of focus is strategic planning and community engagement. She earned her PhD in medical history at the University of Warwick in the UK. Petermann has contributed to several journals in the areas of health-care policy and chronic disease prevention, worked on numerous national and international committees and is the current chair of the M.S.I. Foundation board, an Alberta-based health research funding organization.
Operations Director Dr. Lisa Petermann, PhD
In her role, she is responsible for managing the day-to-day operations of the Institute and for ensuring strategic goals are met.
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Growing team
Institute welcomes new members with diverse backgrounds Dr. Muhammad Rauf Ahsan, MD, earned his medical degree at Dow Medical College in Karachi, Pakistan. He received further training in general surgery and cardiac surgery in Ireland before emigrating to Canada. After finishing medical school, he completed fellowships in adult cardiac, complex aortic and transcatheter aortic valve replacement surgeries at St. Michael’s Hospital in Toronto.
Dr. Muhammad Rauf Ahsan, MD
Before moving to Calgary he worked as a staff cardiac surgeon at St. Mary’s Hospital in Kitchener, Ont., at Southlake Regional Health Centre in Newmarket, Ont., at St. Michael’s Hospital at the University of Toronto, and at the Health Sciences Centre at Memorial University in St. John’s, Newfoundland. His interests lie in aortic and coronary artery bypass surgery. He is now an integral part of the cardiac surgery team in Calgary.
Dr. David Campbell, MD, PhD, is an assistant professor in the departments of Medicine, Community Health Sciences and Cardiac Sciences at the Cumming School of Medicine (CSM). Born and raised in Calgary, he earned his MD and PhD in Health Services Research at the University of Calgary.
Dr. David Campbell MD, PhD
While attending Medical School, Campbell helped start the student-run clinic at the Calgary Drop-In & Rehab Centre. That experience sparked his interest in reducing inequalities in health care delivery. Today, his research focuses on the impact of socio-economic factors—such as homelessness, poverty and food security—on patient outcomes in the area of cardiovascular health and metabolic diseases like Type 2 diabetes. Campbell’s goal is to increase equity in health services delivery and improve access for those who face social disadvantages.
Cardiologist Dr. Robert Miller, MD, has returned to practice in Calgary, where he completed his internal medicine and cardiology residency training. Miller earned his MD at the University of British Columbia. He completed further training in advanced heart failure and transplant at Stanford University and in cardiac imaging at the Cedars-Sinai Medical Center in southern California.
Dr. Robert Miller, MD
Miller’s interests are in advanced cardiac imaging in patients with heart disease and in epidemiology in heart failure and cardiac transplantation. He feels advances in cardiac imaging and new approaches to using statistics will lead to better outcomes for patients by allowing doctors to predict patient risks more accurately and alter treatments accordingly. But Miller isn’t just a doctor and scientist, he is a swimmer with a number of accolades under his belt, including five Canadian Interuniversity Sport championships, won while training at UBC.
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Dr. Jonathan Smirl, PhD, is passionate about finding ways to improve recovery outcomes for people following concussion. His research focus is on what happens to the brain’s blood flow regulation system after a concussion and uses this information to create informed treatment opportunities. This topic is of personal interest to Smirl who suffered from concussions as a high-level athlete with notable accomplishments in rugby, wrestling, judo, rowing, triathlon and swimming. Smirl grew up on Canada’s West Coast and earned his PhD in cerebrovascular physiology at the University of British Columbia’s Okanagan Campus in 2015. Dr. Jonathan Smirl, PhD,
He is an associate professor in concussion research within UCalgary’s Faculty of Kinesiology. Smirl’s current research project includes working as the national lead on exercise-based measures on the NFL-funded SHRed Concussions project. Dr. Amelie Stritzke, MD, is a neonatal physician with training in pediatric cardiology. An assistant professor in the Department of Pediatrics at the CSM, Stritzke’s research interest is in the hemodynamics (how blood flows) of infants. In particular, she is fascinated by the normal hemodynamic changes that occur when babies are born. She hopes a better understanding of the intricate physiology of newborns will allow her to better treat sick infants.
Dr. Amelie Stritzke, MD
Stritzke was born in Germany and received her medical degree in Frankfurt. Her residency was completed in Switzerland. Stritzke has specialty training in ultrasound, echocardiography and Doppler studies in the neonatal population and enjoys teaching bedside ultrasound skills around the world to neonatologists and their trainees. Her travels have taken her across North America and to India, Ecuador, Oman and England. In her spare time, Stritzke enjoys Bikram hot yoga.
Dr. Lin Yang, PhD, an adjunct assistant professor in the departments of Oncology and Community Health Sciences at the CSM, is a scientist with an interest in using big data to improve population health. Originally from China, she earned two masters degrees in kinesiology and statistics at the University of Illinois and a doctorate in epidemiology from the University of Cambridge, UK. Her undergraduate work was in exercise science, which reflects her belief in the importance of physical activity as the cornerstone of health.
Dr. Lin Yang, PhD
The goal of Yang’s research is to make physical activity an easy and accessible option for everyone. She is excited about being involved in Person to Population (P2), a multidiscipline research collaboration with a keen interest in health. Yang is no stranger to physical activity: she is a former marathoner who now practices Tai Chi.
Dr. Lianne Tomfohr-Madsen, PhD, is a clinical psychologist with an interest in how psychological and social factors promote or detract from health. An associate professor in UCalgary’s Department of Psychology, she is particularly interested in the transition to parenthood and interventions that could prevent disease later in life. She is fascinated by mind-body interactions and began studying associations between early signs of cardiovascular disease and depression while an undergrad. Her longtime personal interest in contemplative practices such as yoga and meditation also play a role in her projects. Dr. Lianne TomfohrMadsen, PhD
Tomfohr-Madsen’s lab is working on a number of interventions aimed at promoting mental and physical health in pregnancy. She is also creating screening tools used to direct patients to the most effective resources.
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Understanding abnormal heart rhythms By Dr. Hailey Jansen, PhD
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he heartbeat in a healthy individual is rhythmic and coordinated. Each heartbeat is initiated in the natural pacemaker region of the heart called the sinoatrial node. Electrical signals generated here are conducted from the upper chambers of the heart (the atria) to the lower (the ventricles). This allows these regions of the heart to contract and pump blood to the body. Disruptions in the pattern of conduction of these signals can lead to an irregular heartbeat, called an arrhythmia. Cardiac arrhythmias can cause the heart to beat too slow (called bradycardia), too fast (called tachycardia), with an irregular rhythm (called flutter or fibrillation), or cause an extra heartbeat. Arrhythmias may cause symptoms like dizziness, shortness of breath, palpitations and chest pain.
Types of Arrhythmias
The heart rate for healthy adults falls between approximately 60-80 beats per minute. If the heart rate drops below this point, the heart can’t pump enough blood to meet the body’s needs. Tachycardia, on the other hand, occurs when the heart beats too fast. It can impact the supraventricular or ventricular regions of the heart. Supraventricular arrhythmias are not usually life
between the upper and lower chambers of the heart. This means that both the rate and rhythm of the heart are impacted.
Causes and treatment
threatening but can diminish a patient’s overall quality of life. Ventricular arrhythmias affect the lower chambers of the heart and can be life threatening. Ventricular fibrillation (VF) leads to rapid and ineffective ventricular contractions that prevent the ventricles from pumping blood to the body. Patients with VF require immediate medical attention to shock the heart back into normal rhythm, as the condition can be fatal within minutes. The most common sustained cardiac arrhythmia is atrial fibrillation (AF). When the heart is in AF, the atria quiver at rates exceeding 400 beats per minute due to highly disorganized patterns of electrical conduction travelling within the atria. Some, but not all, of these electrical signals travel from the atria to the ventricles, resulting in uncoordinated contractions
Researchers know that cardiac arrhythmias are caused by alterations in the structure and electrical function of the heart. These changes can be inherited, induced by certain medications, or occur in conjunction with different diseases. Patients with heart attacks, for example, can be more susceptible to developing arrhythmias. Given the potential danger and loss of quality of life associated with arrhythmias, researchers at the Libin Institute are investigating the specific causes and possible treatment of a number of arrhythmias with the goal of improving patient outcomes. Fortunately, arrhythmias are often treatable. While the treatment depends on the specific type of arrhythmia, common therapies include healthy lifestyle choices, medications, or surgical procedures such as ablation. Implanted devices like pacemakers and defibrillators may also be used. Dr. Hailey Jansen is a postdoctoral fellow in the lab of Dr. Robert Rose, PhD.
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Maintaining balance Understanding autonomic dysfunction By Kate Bourne, PhD candidate
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he autonomic nervous system is not something you normally think about in your everyday life. In contrast to the voluntary or somatic nervous system, which controls body movement, the autonomic nervous system works “automatically” to control the involuntary processes in your body including breathing rate, digestion, and your heart rate. The autonomic nervous system can be divided into two main components: the sympathetic nervous system, which is responsible for the body’s “fight or flight” response, and the parasympathetic nervous system, which can be thought of as the “rest and digest” system. When you are startled, for example, the sympathetic nervous system activates the “fight or flight” response by signaling the body to release more adrenaline, increasing your heart rate, breathing rate and perspiration. When you feel your heart pounding in your chest, it is the result of this system. The parasympathetic nervous system is responsible for processes when your
body is at rest, including digestion. A delicate balance of sympathetic and parasympathetic activity is required to maintain a state of balance in the body. If there is a disruption in the function of the sympathetic or parasympathetic nervous systems, this can lead to autonomic dysfunction. If you have ever fainted before, or felt lightheaded when standing up, you may have experienced a type of autonomic dysfunction. Syncope (fainting) and orthostatic intolerance are two common types of autonomic dysfunction, and ones that are studied at the Libin Cardiovascular Institute. Although there are many different causes of fainting, a type of syncope called neurocardiogenic or vasovagal syncope is caused by a sudden drop in heart rate and blood pressure, usually triggered by a stimulus such as prolonged standing, emotional distress or the sight of blood. Orthostatic intolerance occurs when the autonomic nervous system does not respond appropriately to standing. Patients with orthostatic intolerance have severe symptoms
when they stand up and may not be able to do so for long. Two common conditions of orthostatic intolerance are Postural Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH). Patients with POTS experience a rapid heart rate when standing, whereas patients with OH experience low blood pressure. Autonomic dysfunction is diagnosed using autonomic function testing, a series of specialized tests that evaluate the function of the sympathetic and parasympathetic nervous systems. Patients with autonomic dysfunction often experience quality of life impacts, and more research is required to try to understand underlying mechanisms and develop treatments for these disorders.
If you have ever fainted before, or felt lightheaded when standing up, you may have experienced a type of autonomic dysfunction.
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She’s got
heart
By Dawn Smith
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r. Anne Gillis, a Professor in the Department of Cardiac Sciences at the Cumming School of Medicine, has had an amazing career spanning more than 30 years. She is known internationally for her numerous impacts on the field of cardiac electrophysiology, a subspecialty of cardiology focused on heart rhythm problems.
The clinician-scientist has been recognized numerous times by her peers. Notably, she was the 2018 recipient of the Canadian Cardiovascular Society’s Achievement Award, given in recognition of a lifetime of outstanding contributions. Gillis became interested in cardiovascular pharmacology during her second year of medical school at Dalhousie in Halifax, Nova Scotia.
Her passion for cardiology, and in the then-emerging subspecialty of electrophysiology, grew with exposure and was clinched when she completed an elective in the Coronary Care Unit of Victoria General Hospital in Halifax. Attracted by the research environment, the people, and the proximity to hiking and skiing in the Rocky Mountains, Gillis came
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to the University of Calgary in 1986 and hasn’t looked back.
Research
An avid researcher, Gillis has published more than 200 articles and book chapters. She is internationally recognized for her contributions to the understanding of the mechanisms behind cardiac arrhythmias and for new treatments. She has conducted groundbreaking research on the cellular mechanisms of cardiac defibrillation and clinical studies defining the role of atrial pacing for prevention and management of atrial fibrillation (AF), the most common arrhythmia. Patients with AF may experience extreme fatigue, breathlessness and dizziness. They also have an increased risk of sudden cardiac death. Recently Gillis has worked alongside her colleague, Dr. Wayne Chen, to investigate the role of calcium triggered activity and the ryanodine receptor (the microscopic gateway that allows the heart to beat) in atrial fibrillation.
Health-care innovations
Gillis, who maintains her clinical practice, has also contributed to major innovations in health care delivery. She developed standards for nurse clinician-led device clinics and developed the first AF clinic in Canada. Both have become models for care across the nation. In 2004, Gillis led the first Canadian initiative to introduce remote monitoring of Implantable cardioverter defibrillators and pacemakers, which makes life easier for patients because they don’t have to attend a clinic to have their heart monitored.
Leadership skills
Gillis is also a respected leader, with a number of important roles under her belt. Notably, in 2012 to 2013, she served as the president of the Heart Rhythm Society, a respected organization that represents medical, allied health and science professionals specializing in cardiac rhythm disorders from more than 70 countries. She has also held numerous positions on the Canadian Cardiovascular Society Academy board, including vice president and president.
Dr. Anne Gillis, MD, is a physician and researcher recognized internationally for her work in the field of cardiac electrophysiology. Photos by Britton Ledingham. Gillis has significantly contributed to health-care guidelines and position papers, which recommend the best treatments for patients based on the latest discoveries. In 1996, Gillis was the first female in UCalgary’s Dept. of Medicine to be promoted to professor. She played an instrumental role in the development and growth of the Libin Institute as deputy director, a position she held until late 2019. Gillis says her career was driven by a desire to improve outcomes for patients, adding she was fortunate to be on an amazing team of researchers and clinicians like Drs. Brent Mitchell, George Wyse, Henry Duff, Katherine Kavanagh and Derek Exner. She is also thankful for support from Alberta Innovates (formerly the Alberta Heritage Foundation for Medical Research), which allowed her to carve out research time from her busy clinical practice. As she prepares to retire, Gillis can’t help but think about the amazing changes she has witnessed in her field.
“There have been tremendous advances in technology over the past three decades that have dramatically improved patient outcomes,” she says, noting some examples include devices like implantable cardioverter defibrillators and catheter ablation, which can cure patients with irregular heartbeats. Looking to the future, Gillis anticipates ever-increasing technology advancements that will allow for more precision diagnostics and treatment of arrhythmias. “We are just seeing the tip of the iceberg of precision medicine in our field,” she says. “There’s room for excitement.” She anticipates the Libin Institute will maintain its world-class standing in the field, pending adequate resources. “I hope [electrophysiology] will remain a core,” she says. “We don’t have as much of an opportunity to recruit scientists due to budget constraints. We need ongoing resources.”
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Keeping the beat Innovative cardiologist retires from successful medical career
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here are those who work to live and those who live to work. We often find the latter group to be peculiar, wondering what motivates them. Solidly in the live to work camp, Merril Knudtson would simply tell you he is curious by nature. A 75-year-old mild mannered man, Knudtson recently retired from a medical career as an interventional cardiologist that spanned nearly 40 years in Calgary as both a professor and clinician. Now, he is being honoured by having a catheter lab named after him at the Foothills Medical Centre. Perhaps Knudtson’s biggest accomplishment was his commitment to advance a craft that, at the time, was so new dictionaries didn’t even have a definition for it yet. Knudtson began medical school at the University of Calgary in 1972, part of just the third class of aspiring physicians. Fascinated by the human heart, Knudtson later relocated to Emory University in Atlanta, Georgia, for three years to study at what was then North America’s preeminent
By Trevor Bacque cardiology program. It was there his future was unknowingly written for him. He studied under the father of interventional cardiology, Dr. Andreas Gruentzig, a Swiss cardiologist who conducted the first-ever successful balloon angioplasty and was subsequently recruited to Emory. “Through a stroke of fortune, I was able to work with Dr. Gruentzig for a six-month period, and that really shaped my career in a really major way,” says Knudtson. Enrapt by the novel practice of interventional cardiology, Knudtson returned to Calgary and was one of a handful of doctors working in this specialized field, which he describes as an “electric environment in which to work.” After convincing colleague Dr. David Roth to begin training new recruits, the two began the first-ever interventional cardiology residency program in 1983. Sharp young talents from around the world began flashing passports destined for training in Calgary.
“We were able to develop this program and really have a profound influence. Being able to have your influence spread in that way was a real jolt,” says Knudtson. To date, more than 75 physicians have completed the program and are practicing in locations around the world. Knudtson made another critical choice that would codify heart patients not just in Alberta but across the country, thanks to a commonly shared database he termed APPROACH—Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease. Created in 1995, he offered APPROACH to every Canadian medical school and physician for free. The database was still in its infancy and Knudtson took it upon himself to input every shred of detail related to coronary heart disease cases and add critical accountability to the resourceintensive procedure. It didn’t take long for other physicians to see the work Knudtson was establishing for Canadian medical perpetuity by promoting coronary artery disease research.
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Dr. Merril Knudtson, MD, is retiring after a 40-year career in cardiology that helped put Calgary on the map.
Today, every province and territory in Canada implements aspects, if not a carbon copy, of APPROACH. “If APPROACH was good for Alberta, it should be good for Canada,” he says of the database. “If any people contacted us with an interest in looking at what we were doing, we would strongly support their using those techniques. It literally happened from coast to coast. To see your colleagues buy into it and support it, I think it contributed in a very, very major way for momentum and my own personal commitment.” In 2012, Knudtson was 30 years into his storied medical career when he received perhaps the most humbling shoulder tap of all time—a recipient’s notice of
the Order of Canada—for his trailblazing work within interventional cardiology. Knudtson's work was recognized nationally, but perhaps the effects were realized most significantly at home. "It seemed really a bit of a dream," he says. Dean Traboulsi studied under Knudtson before becoming his colleague in the ‘80s. “Merril was an excellent cardiologist, teacher and a true leader, but more importantly a great innovator,” says Traboulsi. “We all learned together at that time of early days angioplasty, but he was clearly ahead of the game in many ways.” Traboulsi remembers seeing Knudtson manually modifying catheters to fit aberrant arteries. Beyond
that, he said Knudtson was adept at advancing medical science and patient care. “There were all kinds of things he had to deal with in addition to dealing with patients with complex medical problems,” he says. “He was the whole package, really.” Those comments are echoed by Dr. Bryan Har, another interventional cardiologist who worked with Knudtson for 11 years and received mentorship from him, as well. “He’s incredibly patient, and from a procedure standpoint, he can talk you through very challenging cases,” says Har.“Even when you think you’ll fail, he can talk you through it and build that confidence rather than taking over.”
Going global Made-in-Calgary imaging registry to expand internationally By Dawn Smith
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r. James White, MD, director of the Libin Institute’s Stephenson Cardiovascular Imaging Centre and a professor at UCalgary’s Cumming School of Medicine, has spent over a decade developing novel ways that medical images can help predict patient outcomes. His expanding research program, called the Personalized Diagnostics Program (PDP), focuses on how data collected at the time of heart imaging tests can be used to predict an individual’s risk of developing cardiovascular disease or its complications. These tools allow physicians to tailor care plans to each individual patient, a concept called Personalized Medicine. “While today’s electronic health records are excellent for monitoring patient care and patterns of health, they lack the raw data
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created by diagnostic tests,” says White. “Imaging tests produce thousands of data points that can be used to describe each patient’s disease. By starting with this data and adding relevant data from the medical record, we believe we can make much more accurate predictions for patients.” According to White, the team is looking to predict such things as whether an individual will be admitted to hospital with heart failure, develop an arrhythmia or experience sudden cardiac death. Getting to this point hasn’t been easy as generating predictive models requires a large amount of data. White and his team have asked more than 18,000 patients with heart disease to contribute by participating in the Cardiovascular Imaging Registry of Calgary (CIROC), a study of patients with heart disease undergoing imaging tests in Calgary. On average, eight out of 10 patients have consented. The registry is one of the largest patientconsented databases for cardiac imaging in the world. Every set of images has been linked to standardized disease descriptions, patient-reported health questionnaires, echocardiograms, laboratory tests and health outcomes. Data scientists on White’s team analyze the data using artificial intelligence methods, such as machine learning and deep learning. They look for patterns in the data that are difficult to see without these more advanced techniques. These patterns are helping researchers discover new ways of diagnosing certain types of disease; cluster individuals that have similar characteristics; and develop computer models that can predict when future events will occur. The CIROC project has already led to powerful demonstrations of personalized medicine. For example, from 6,000 patients with no prior history of arrhythmia (heart rhythm abnormalities), White’s team was able to build a computer model that can predict when and if someone will develop atrial fibrillation, a common arrhythmia that is linked to strokes.
Dr. James White, MD, PhD, is launching his cardiovascular imaging registry internationally. The resulting data will be used to validate and build relevant risk prediction models for patients across a wide range of cardiovascular diseases. Photos by Britton Ledingham. They are also refining a model to predict future heart failure hospital admissions and have developed a method of automatically diagnosing heart disease directly from MRI images. White is now expanding his research program to a global network of hospitals. His team recently combined data from 12 hospitals in Canada, the US, Spain and Italy to show the value of cardiac MRI data in predicting cardiac events in patients with dilated cardiomyopathy. The study, recently published in the peer-reviewed journal Circulation: Cardiovascular Imaging, found that cardiac MRI can predict life-threatening arrhythmias in this group of patients. This emerging research network, called MINICOR, will now adopt White’s established approach to research, implementing it at sites across Canada, US, South America and Europe. The plan
is to launch the network at 10 institutions this year, with the goal of enrolling 60,000 to 70,000 patients by 2025. MINICOR will greatly expand the team’s potential to build and validate relevant risk-prediction models for patients across a broad range of cardiovascular diseases. “It has been a tremendous challenge, but we are well on our way and very much looking forward to getting this important project off the ground,” said White of MINICOR, adding his team has been working on getting the project launched for more than two years. This project is being funded in part by donations raised at the Libin Institute’s 2019 gala, The Beat Goes On. The Institute is grateful for its community partners.
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Inside view
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Powerful microscope provides unique perspective By Dawn Smith
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ou can’t help but notice the smiles on the faces of a number of scientists at the Libin Cardiovascular Institute.
The excitement is over the recent arrival of a powerful new microscope with the ability to penetrate through layers of tissue to capture images of what lies beneath. The $1.2 million, two-photon confocal microscope is a boon to scientists at the Libin Institute. One of those scientists is the Libin’s Director of Research, Professor Rob Rose, PhD, who will use the confocal microscope to look at heart Purkinje cells, which are specialized conducting fibers that have a role in the heartbeat. “It allows us to look at intact organs at different depths,” says Rose, whose research interests lie in understanding the problems of the heartbeat at the cellular level, including atrial fibrillation, a common heart rhythm disturbance that can cause breathlessness, fatigue and dizziness and is linked to sudden cardiac death. “This is important for understanding how the cells are interacting with one another.” The microscope, which fills a room at the Institute, was purchased, in part, from funds raised at the fourth annual The Beat Goes on Gala, put on in 2017 to raise funds for cardiovascular research, education and care. Canadian Pacific Rail (CP) was the signature sponsor of this event. Rose is grateful for the community’s generosity, noting he expects the microscope to have a large impact on his research program. “Discovery science wouldn’t be possible without the support of the community,”
(Left) Dr. Zhenpeng Song, a postdoctoral fellow in the lab of Dr. S.R. Wayne Chen, PhD, peers through the Libin Institute’s new confocal microscope, which can penetrate layers of tissue and capture images of what lies beneath. The powerful new tool will help scientists at the Libin to better understand how the heart works. (Above) Dr. Song examines data from the microscope. Photos by Britton Ledingham. says Rose. “We need each other to make a real impact in the lives of patients.” It took some time for the specialized piece of equipment to be set up, and for the necessary training to occur, but the confocal is now up and running. Several spectacular images are being captured by scientists working with Dr. Wayne Chen, PhD, who has been recognized as a Clarivate Highly Cited Scholar for his work in mapping the
structure of the ryanodine receptor, which plays an important role in heartbeat as it opens and closes to allow the movement of calcium at a cellular level within heart cells. According to Rose, in addition to its use in individual research programs, the confocal microscope could lead to collaboration within the Institute and beyond. CP also directed funds for the Institute raised at their CP Has Heart Clear Rounds for Heart event in 2017 and 2018.
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Forward thinking Q&A with Libin Institute's new research director
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e sat down with Dr. Robert Rose, PhD, the Libin Cardiovascular Institute's new research director, to discuss his views on cardiovascular research in Calgary and to hear his plans for the future. Why did you decide to take on this role? I agreed to take on this role so that I can help enhance the research efforts of our Institute. Research continues to excite me and challenge me every day. In this role I will have the opportunity to interact more extensively with our members, learn more about what we are doing, and to help facilitate our goals and efforts to be a leading cardiovascular research centre.
How do you feel about being chosen? I’m honoured and excited to have been chosen for the role.
efforts. All of this speaks to the very high quality of our research environment. We will continue to strive to be even better.
How do you view the research environment at the Libin Institute? We have a very strong, vibrant and diverse research enterprise at the Libin Institute. Overall, we are performing well from the perspectives of obtaining funding, publishing high-quality papers and seeing our work highly cited. We are fortunate to be in an environment where we have strong support from the community, which has been instrumental in helping us obtain powerful, state-of-the-art infrastructure to support our research
What are your goals as research director? My goal is to understand the needs of our investigators in order to help advance our research mission. In doing so, I hope to see our collective scientific success and productivity continue to increase and for the Libin Cardiovascular Institute to be recognized as a worldclass centre for cardiovascular research.
Learn more about research at the Libin Institute at libin.ucalgary.ca/research
LIBIN LIFE
Managing risk
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Researchers examine implantable cardiac devices in the fight against sudden cardiac death
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By Dawn Smith
t isn’t uncommon to hear that someone has collapsed suddenly, become unresponsive and died from something related to the heart.
an elevated risk of SCD following a heart attack, but we don’t know who,” she says. Fortunately, researchers within the Libin Institute are working to address this question.
Many chock these deaths up to heart attacks, but sudden cardiac death (SCD) is often the culprit. SCD is the largest cause of natural death in North America, taking the lives of 360,000 adults annually.
Kavanagh is the local principle investigator for the REFINE-ICD study, a multi-centre trial led by her colleague Dr. Derek Exner, MD, a heart-rhythm specialist. The project studies the risk of SCD in individuals who have suffered a heart attack within the past five years and who fall within the mild to moderately affected group.
SCD is usually caused by a very rapid heart rhythm originating in the left ventricle – the heart’s main pumping chamber. The rapid heart rhythm causes the blood pressure to drop, which in turn means that not enough blood is pumped to the vital organs including the brain, kidneys and liver. Although these deaths may seem random, there are certain patient groups who are at a higher risk of SCD, such as those who have suffered a heart attack (myocardial infarction). The risk is higher for these patients because of scarring on the ventricular muscle of the heart caused by blockages in one or more arteries in the heart. The scarring can reduce the heart’s ability to pump and is also the site where an arrhythmia can originate. According to the REFINE-ICD website, heart attack survivors are four times more likely to die of SCD, especially those with reduced heart pumping function, but there are options for improving the odds. Implantable cardioverter defibrillators (ICD), devices made to restore normal rhythm to heart, have revolutionized treatment for those at risk of SCD.
Participants are asked to wear a Holter monitor, which records their heart rhythm, for 24 hours. The results are screened for specific electrical signals as studies suggest that the presence of certain abnormalities in electrical signals may increase the risk of SCD by up to nine times. But there are limitations to who is eligible to receive an ICD. Patients with severe loss of heart function (measured by left-ventricular ejection fraction [LVEF] of 35 per cent or lower) are given an option to have the device implanted, while patients with mild to moderately reduced LVEFs (36-50 per cent) aren’t. Instead, patients in the mildly to moderately impacted group are generally treated with medication and lifestyle changes. This cutoff poses a problem, according to the Libin’s Dr. Katherine Kavanagh, MD, a cardiologist with a specialty in treating heart rhythm problems. “We know a certain number of patients in this [mild to moderate] group will have
Patients are then randomized into two groups: those who receive ICDs and those who receive standard care following a heart attack. According to Kavanagh, ICDs aren’t necessary or beneficial for all heart attack patients. The goal of REFINE-ICD is to determine if there are patients in this mild to moderate risk group who would benefit from an ICD so that we can provide more precise care for future patients with similar characteristics and/or cardiac abnormalities. REFINE-ICD is funded by CIHR and CANN-NET. Recruitment for the study is still underway.
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Getting to the
heart
of the matter Research project explores ways to increase number of patients attending follow up appointments after a heart attack By Dawn Smith
I
t is estimated that heart attack survivors are four more times more likely to die suddenly from cardiac arrest, even if they receive good follow-up treatment.
severe enough— patients may need an implanted cardiac defibrillator to identify and treat the heart rhythms that cause cardiac arrest.
Researchers know about 10 per cent of heart attack survivors are left with pump dysfunction caused by scar tissue. The more severe the damage, the higher the risk of cardiac arrest, which is estimated to cause half of the deaths from heart disease in North America.
Physicians recommend patients have a follow up echocardiogram, or ‘echo’, a special ultrasound test that measures heart function, three to six months after a heart attack to assess their risk of cardiac arrest, but researchers have found that doesn’t always occur.
Pump function often improves within the six months following a heart attack, but if it doesn’t— and the damage is
“The problem is, many patients aren’t examined at the six-month mark,” says Dr. Stephen Wilton, MD, a cardiologist and researcher at the Libin Cardiovascular Institute. “In fact, 50 per cent of patients don’t get follow up echocardiograms, increasing their risk of cardiac arrest.”
"Fifty per cent of [heart attack] patients don’t get follow up echocardiograms, increasing their risk of cardiac arrest.” — Dr. Stephen Wilton
Investigators don’t know why patients don’t follow up or whether the story is similar across Canada. In fact, there is even a gap in the knowledge of how many people are at risk of cardiac arrest.
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The facts
But researchers at the Institute are hoping to change that with phase one of the Acute Myocardial Infarction Quality Assurance (AMIQA) project. Led by Wilton, the study is following patients who have some degree of heart pump dysfunction after a recent heart attack. In addition to tracking the number of these patients who have an echo, the study asks patients, their doctors, and health system officials to complete a survey so investigators can better understand why some patients may not be getting the tests and treatment they need. “We want to find out how often the ejection fraction [which measures heart function] is being checked around the country,” says Wilton. “We also want to know if isn’t happening, why not.” Wilton explains there are a number of barriers for patients, including long waiting lists for echocardiograms in some areas, difficulty obtaining follow-up appointments with cardiologists and possible gaps in knowledge for primary care providers. He adds the specific knowledge being gained from the data collected in phase one is critical in the project’s long term objective of reducing the number of heart attack survivors dying from cardiac arrest in Canada.
He is excited that investigators will have their answers soon. Phase one, began in 2017 and has enrolled more than 500 heart attack survivors from 15 centres across Canada. Researcher hope to conclude the project in the spring of 2020. Wilton said the next phase will be focused on developing strategies to improve patient care. He is optimistic about the results, citing a previous smaller-scale study in Calgary that was instrumental in increasing the number of follow-up exams by 25 per cent. “The results of this project should show us the extent of this problem around the country, and hopefully will point to some simple, yet effective, tweaks to the process of care that will lead to better uptake of follow-up echo imaging in patients at risk of cardiac arrest," says Wilton. AMIQA is funded by the Cardiac Arrhythmia Network of Canada NCE, with additional financial support from the Libin Cardiovascular Institute, Medtronic Canada, Boston Scientific and Abbott. To learn more about this exciting research project, or to take part, visit www.ucalgary. ca/research/participate/study/13979/ acute-myocardial-infarction-qualityassurance-canada-phase-1.
According to the Government of Canada, heart disease is the second leading cause of death in Canada, accounting for almost 20 per cent of all deaths in 2012. About 2.4 million Canadians live with heart disease. About 578,000 Canadians have had a heart attack. Heart attack survivors are at an increased risk of sudden cardiac arrest, which occurs when the heart suddenly stops beating. The large majority of premature heart disease and stroke is preventable through healthy lifestyle changes. Healthy eating, physical activity, managing stress and stopping smoking are all important factors in preventing heart disease.
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Making a difference
Institute recognized globally for expertise in studying, treating mysterious condition By Dawn Smith
A
busy mother of two and fulltime teacher, Kristina Sayer, 37, seems to have loads of energy. It’s hard to believe that the optimistic, outgoing wife and mom was confined to her bed with a bevy of debilitating symptoms just 18 months ago. The mysterious symptoms of extreme fatigue, headaches, chest pain, a racing heart and dizziness came on Sayer suddenly, with no obvious trigger. Concerned, she saw her doctor and received an electrocardiogram (ECG) – a standard test to check on her heart health. All of Sayer’s tests came back as normal, yet her condition worsened over the summer of 2018 with additional problems like debilitating migraines, lightheadedness and stomach problems. “I felt like my legs would go out from under me at any moment and I would go ‘splat,’” she says, adding she was in and out of emergency departments seeking the cause of her symptoms. But there was no diagnosis, merely the suggestion she might be stressed. By the end of the summer, Sayer couldn’t
keep food down. Caring for her two young children was difficult. She knew going back to her classroom was out of the question.
nervous system disorder impacting up to one per cent of the population worldwide (60,000 to 300,000 Canadians).
“At my worst, I couldn’t get out of bed. It was so debilitating and frustrating because I couldn’t do anything to fix it,” she said.
Raj helped the young mom get her condition under control. Today, Sayer is back teaching and describes her condition as “manageable.” Sayer’s POTS story is a bit unusual in that she received her diagnosis within months of her first symptoms.
Fortunately, while at the emergency department in Three Hills, a triage nurse asked if Sayer had received an ECG while standing. The test is generally performed while the patient is lying, and Sayer hadn’t had one in an upright position. The results of the ECG were immediate and dramatic. “I was upright for about two minutes and my heart rate was up to 184 beats per minute,” said Sayer. “The doctor made a few phone calls to colleagues and that’s when I first heard the term POTS (postural orthostatic tachycardia syndrome). Sayer was relieved to finally receive a diagnosis and was referred to Dr. Satish Raj, MD, a Libin cardiologist and researcher who specializes in autonomic nervous system disorders like POTS. It is a relatively common autonomic
On average it takes more than five years for patients to receive a diagnosis. However, her sudden onset and debilitating conditions are similar to the stories of many POTS patients. According to Raj, who is one of just a handful of POTS clinician-researchers in Canada, symptoms of the condition vary greatly from patient to patient, but the common thread is a dysfunction of the autonomic system. When POTS patients stand up, their heart rate increases excessively, resulting in low blood pressure that leaves them feeling lightheaded and faint. The condition can impact nearly every system in the body. Besides lightheadedness, a racing heart and stomach
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For more information on POTS, watch this video at https://vimeo.com/187404694 or visit cumming.ucalgary.ca/rajlab/autonomic-disorders/ pots. Patients and caregivers impacted by POTS can find a support group at the following link: dysauttonomiainternational.org/support. problems, patients can present with body pain, brain fog, fainting and gut issues, amongst other debilitating symptoms.
whose journey to a POTS diagnosis took years and was fraught with misdiagnoses, including cancer.
of POTS. All three studies were supported by research grants from Dysautonomia International.
According to Raj, the average age of onset is 14 years, and at least 90 per cent of POTS patients are female. However, the condition is not limited to teenagers. Half of all patients first develop POTS symptoms in adulthood.
Besides seeing patients from all over Western Canada, Raj, Sheldon and Morillo give talks around the globe, sit on advisory committees and write guidelines to help improve awareness of POTS and enhance the quality of life for people who live with this condition.
The team is also training the next generation of Libin researchers.
Although POTS was first diagnosed at the Mayo Clinic in 1993, the condition is still relatively unknown by the public and even health care practitioners. Patients are often misdiagnosed with anxiety or other conditions before receiving a proper diagnosis. The causes of POTS aren’t known, but researchers at the Libin Cardiovascular Institute are working to change that. Their efforts are paying off. The team made up of Raj, Dr. Robert Sheldon, MD, and Dr. Carlos Morillo, MD, all cardiologist-researchers at the Libin Institute, is recognized internationally as a centre of excellence in POTS research. Lauren Stiles, founder and President of Dysautonomia International, a nonprofit patient advocacy organization that funds research, educates physicians and raises awareness about POTS and other autonomic disorders, says there are fewer than 100 expert POTS experts worldwide. “The Libin Institute is a leader in the treatment and research of autonomic nervous system disorders in Canada and around the world. We are very grateful for the research and clinical care going on in Calgary,” says Stiles,
Recently, Raj and Sheldon were part of the Canadian Cardiovascular Society committee that wrote and presented a position paper on the condition at the Canadian Cardiovascular Congress – the largest gathering of cardiovascular specialists in Canada. Chaired by Raj, the document makes suggestions about how to diagnose and treat POTS based on the latest research. Raj is also the president of the American Autonomic Society, serves as a medical advisor to many POTS patient groups, including POTS UK and Dysautonomia International. There is also a large research component to the work of these physicians. For example, several projects are underway in the Raj lab, including a cardiac MRI study in POTS patients and an international, collaborative study looking at different methods of detecting an antibody that has been found in some patients with the condition. (See more at https:// cumming.ucalgary.ca/labs/calgaryautonomic-investigation/home). Sheldon is currently studying two medications in the treatment
Kate Bourne, is embarking on a PhD in Cardiovascular and Respiratory Science at the Cumming School of Medicine with her supervisor, Raj. She is highly interested in understanding POTS, including the impact it has on patients. Using data from The Big POTS Survey, an international study of more than 8,000 POTS patients developed by the University of Calgary, Vanderbilt University and Dysautonomia International, Bourne recently completed a study on how POTS impacts the lives of patients economically – something previously underestimated. “People don’t recognize the huge impact POTS has on young women in their formative years,” she says. “Women who should be going to school or working are instead debilitated with this condition.” Although POTS is not well understood, Stiles is optimistic about the future, given the targeted research and patient engagement projects underway at places like the Libin Institute. “We are making headway,” she said. “POTS is not quickly diagnosed or easy to treat, but we are making progress in reducing diagnostic delays and finding more effective treatments.”
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A COMPREHENSIVE
approach The goal of the Libin Cardiovascular Institute is to provide optimal cardiovascular health. Our clinical and research members are dedicated to working together to make this goal a reality. Here is a small sample of the areas of focus of our researchers and clinicians.
MENTAL HEALTH & WELLNESS The Institute recognizes that mental wellness is a vital part of overall health. Poor mental health can lead to mental and physical illness and impact ability to cope with stressful situations. Libin researchers and clinicians know that the mental health of cardiovascular patients, especially those who have life-altering conditions and implantable devices, may suffer. They are combating this through research, awareness and patient resources, like Calgary’s mental health device clinic. SEE STORY PAGE 40
PREVENTION & PROMOTION Cardiovascular disease is the No. 1 killer globally for men and women. That statistic may sound grim, but an estimated 80 per cent of cardiovascular diseases, including heart disease and stroke, are preventable. Researchers are dedicated to understanding the factors that influence lifestyle choices and their impact on cardiovascular risk. Our researchers are monitoring and analyzing global data, informing government policies and health guidelines. But they are also facilitating change for local groups and individuals, by investigating ways to nurture physically active communities. For example, Libin Research Collaborative, P2: Person to Population, is coordinating a mall-walking program in hopes of facilitating real lifestyle changes for Calgarians. libin.ucalgar y.ca/p2
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SEX & GENDER Our biological sex and sociocultural differences (gender) influence our risk of developing certain diseases, how often we will seek care and how our disease will progress. The Libin Institute’s newest research collaborative, CV&Me, is focused on understanding how our sex and gender differences influence cardiovascular health. The goal is optimal cardiovascular health for everyone.
libin.ucalgary.ca/cv-me
HEART & VASCULAR SYSTEM Heart disease takes the lives of 12 Canadian adults each hour, and many more live with the condition. Libin researchers are working to change this. In fact, heart health is the Institute’s main area of focus. Our researchers work closely with health-care providers to solve real-world problems in the clinic with the goal of improving patient outcomes. For example, surgeon scientist Dr. Paul Fedak, MD, PhD, Libin director, was recently part of a team that discovered a cell with the potential to heal in the fluid surrounding the heart. The result is immediate clinical change. The Libin Institute is also highly interested in improving the experience of patients in care. Recently, members launched the first nurse-practitioner run cardiac clinic in Canada and the results are promising. SEE STORIES ON PAGES 28 AND 44
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A league of his own Up-and-coming lab director poised to make medical breakthrough
By Trevor Bacque
I
t’s a well-known fact in medical research that major advances are time consuming and require dedication. On average, it takes roughly 17 years to see research evidence reach the clinic. Well, that was a little too long for Dr. Aaron Phillips, primary investigator and lab director at the Libin Cardiovascular Institute. He and his team recently repurposed a neurostimulator for spinal cord injury patients with cardiovascular disorders, allowing them to regain function. To date, he and his team—a veritable who’s who of world-leading post docs and clinicians—have proven the technology. Oh, and they did it in 27 months. Since arriving at the Libin Institute in September 2018, Phillips has made it a point to make a dramatic shift toward patient-centred outcomes.
"People are moving after decades of being chronically paralyzed. Their blood pressure is now stable so they can be upright without feeling lightheaded." —Dr. Aaron Phillips, researcher
He is in the process of launching a clinical trial into the potential therapy.
without feeling lightheaded. How far we can take them? We don’t know yet.”
“People not familiar with spinal cord injury often focus on a person in a wheelchair, and we think they want to get out of that wheelchair as their primary goal,” he says. “However, there are huge hidden clinical consequences for these patients that they’ll rank well above walking again.”
Phillips’ dedication and ingenuity has directly generated approximately $2 million in funding since 2017. In addition, his research is published in high-ranking medical journals such as Neurology and JAMA Neurology.
Those concerns range from bladder, bowel and sexual function to cardiovascular stability and a consistent blood pressure Thanks to the neurostimulator, the common issue of orthostatic hypotension, or extremely low blood pressure, Phillips is starting to see major improvements in patients’ health. The device works by sending electrical currents to cells within the sympathetic nervous system, reactivating cardiovascular functions, and, as a result, transforming patients’ lives in radical fashion. “With this technology we’ve raised the ceiling,” says Phillips. “We’ve changed where people with spinal cord injuries can get to during recovery, and we don’t know how high the ceiling is. People are moving after decades of being chronically paralyzed. Their blood pressure is now stable so they can be upright
He also founded a company, StimSherpa Inc., to both increase the speed of regulatory approval and scalability when spinal cord patients are implanted with the device. With a passion for interdisciplinary co-operation to achieve greater patient outcomes, Phillips has a distinctly 'we not me' approach in his lab. “We don’t work in silos, we work together,” he says, adding he has partnered with other health institutes at the Cumming School of Medicine, including the Hotchkiss Brain Institute and the McCaig Institute for Bone and Joint Health. “To work across the translational spectrum, you need buy-in from people living with the condition, their families, the physicians providing direct care and the institutes. Libin is uniquely collaborative.” One patient who has felt the positive effects of Phillips’ collaborative approach to convalescence is Richi Gill, an upper
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Researcher Dr. Aaron Phillips, PhD, conducts spinal cord research in his lab at UCalgary’s Foothills Campus. His goal is to improve the quality of life for spinal cord patients, with a focus on the cardiovascular system of these patients. Photos by Britton Ledingham. GI doctor and bariatric surgeon. In the summer of 2018, Gill was paralyzed following a freak boogie board accident while on vacation in Hawaii. Like many patients Phillips has observed, Gill suffered from hypotension, often resulting in fainting, dizziness and poor sleep hygiene. Immediately he was put onto medication, which had varying levels of success. However, after being implanted with a neurostimulator in November 2018, he was quickly able to quit his medication and regain a quality of life through regulated blood pressure. Gill’s other symptoms faded away, as well. Today, he is excited about the future of spinal cord care thanks to people like Phillips.
“That’s not an easy thing to deal with—basic and clinical research— they do a good job to integrate that,” says Gill. “It’s pretty impressive.”
the world. That person is Aaron. The high-quality work that he is doing will soon get the attention of the world.”
Another impressed physician is cardiac surgeon Dr. Paul Fedak, MD, PhD, the director of the Libin Cardiovascular Institute.
Phillips conservatively estimates that within 10 years neurostimulator implants will become standard care for people with spinal cord injury, a time line he is keen to shrink.
Despite working with Phillips for less than one year, he already knows his lab is going to be making medical advances that will be discussed for years to come.
“The reason why I dedicated my career to medical research was to make discoveries that would rapidly improve health on a population scale,” he says.
“Not only can he see the big picture, he can manage the fine details,” says Fedak. “That’s someone very special who will do groundbreaking science and change
“To be able to do that is what makes me want to do this every day. I don’t even consider what I do a job. It’s really a passion as opposed to a job.”
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Cell discovered that can
heal hearts Researchers make fundamental scientific discovery that could lead to new ways to repair damaged hearts
By Jordanna Heller & Steve Macfarlane, Cumming School of Medicine
U
niversity of Calgary researchers are the first to discover a previously unidentified cell population in the pericardial fluid found inside the sac around the heart. The discovery could lead to new treatments for patients with injured hearts. The study led by Drs. Paul Kubes, PhD, Justin Deniset, PhD, and Paul Fedak, MD, PhD, was published in the summer of 2019 in the internationally recognized journal Immunity. The Kubes lab, in collaboration with the Fedak lab, found that a specific cell, a Gata6+ pericardial cavity macrophage, helps heal an injured heart in mice. The cell was discovered in the pericardial fluid (sac around the heart) of a mouse with heart injury. Working with Fedak, a cardiac surgeon and director of the Libin Cardiovascular Institute, the team found the same cells within the pericardium of people with injured hearts, confirming that the
repair cells offer the promise of a new therapy for patients with heart disease. “The fuel that powered this study is the funding from the Heart and Stroke Foundation of Canada, the collaboration between two major research institutes at CSM (Snyder and Libin) and the important contribution of philanthropy from the Libin and Snyder families to obtain imaging equipment available to very few programs globally,” says Kubes, the director of the Snyder Institute for Chronic Diseases at the Cumming School of Medicine (CSM) and professor in the Department of Physiology and Pharmacology. Heart doctors hadn't explored the possibility that cells just outside the heart could participate in healing and repair of hearts after injury. Unlike other organs, the heart has a very limited capacity to repair itself, which is why heart disease is the No. 1 cause of death in North America. “Our discovery of a new cell that can help heal injured heart muscle will
open the door to new therapies and hope for the millions of people who suffer from heart disease," says Fedak, a professor in the Dept. of Cardiac Sciences. "We always knew that the heart sits inside a sac filled with a strange fluid. Now we know that this pericardial fluid is rich with healing cells. These cells may hold the secret to repair and regeneration of new heart muscle. The possibilities for further discovery and innovative new therapies are exciting and important." Working together and bringing expertise across disciplines, the basic researchers working with the cardiac surgeon and researcher, have identified the cell in
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Drs. Paul Fedak, MD, PhD, Paul Kubes, PhD, and Justin Deniset, PhD, discovered that a cell in the pericardial fluid surrounding the heart has healing properties that may help repair injured heart muscle. Photo by Adrian Shellard.
less than three years — a relatively quick time frame to move research from the lab and animal models to people. Dr. Justin Deniset, PhD, who is the first author on this study, has worked on this research since it began. “This project stemmed from wanting to integrate my previous research training in cardiovascular disease with my current focus on the immune system within the Kubes laboratory," he says. "The diverse expertise in both areas combined with the state-of-art infrastructure we have here at the CSM made it the ideal setting to undertake such an endeavour. Collaborating with a clinician
scientist such as Dr. Fedak provided a different perspective to our research questions and enhanced the impact of our work. This type of partnership also paves the way to explore how to translate our findings from the bench to the clinic, which is ultimately our goal." Next Fedak hopes to recruit a basic scientist to move the research to a broader study of human heart repair. This new program will extend the collaboration between basic and clinical research to find potential new therapeutics to improve heart repair. Philanthropy fuels research advances Both the Kubes and Fedak labs have a solid foundation of support from some of UCalgary’s most generous philanthropic partners, including the Snyder, Libin and Campbell families, whose contributions over the years have allowed the researchers to bring in cutting-edge technology and talented trainees to advance their work and make a global impact in health outcomes.
“The results are spectacular — a fundamental scientific discovery with enormous clinical relevance. It highlights that supporting any part of the CSM enterprise can result in a significant impact in ways you may not expect,” says Fedak. “I am thankful for the support of these families for strengthening my laboratory and allowing me to successfully collaborate with a world-class scientist from the Snyder Institute. We may have invented a new field of research — immuno-cardiology!” This research is supported by the Heart and Stroke Foundation of Canada, the Canadian Institutes of Health Research, the Canada Research Chairs Program and the National Institutes of Health.
“The results are spectacular — a fundamental scientific discovery with enormous clinical relevance." — Dr. Paul Fedak, MD, PhD
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Mentorship matters Q&A with the Libin’s new education director
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e sat down with Dr. Jennifer Thompson, PhD, the Libin Cardiovascular Institute’s new education director, to discuss her views on education and mentors and to hear her plans for the education portfolio at the Institute. How long have you been an educator? I began my teaching career while doing postdoctoral studies in the Vascular Biology Center at the Medical College of Georgia at Augusta University. As an adjunct professor, I taught several undergraduate and graduate courses in the Kinesiology Department as well as in the Biological Sciences Department. My teaching experience was a nice complement to my research activities because it put me in a position to have a direct impact on students and help them achieve their potential. Why is education important to you? Trainees aren’t just driving the research of today, they will be the principal investigators and leaders of tomorrow.
To advance biomedical research in Canada, it is critically important to retain the strongest students and adequately train them to develop internationally competitive research programs. Why did you agree to take on this role? I am really excited about taking on the role of education director. I have always been passionate about education and am excited to contribute to the mission of the Libin Institute. What is your education philosophy? The biomedical research enterprise has evolved – there are higher expectations for collaborative, interdisciplinary and translational research as well as connecting to the broader community. We need to equip our trainees with the full complement of skills required to be successful in this new landscape. I believe this involves providing multilayered training that extends beyond the laboratory and positions trainees to apply their knowledge and skills to a variety of career trajectories.
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What is the ideal education environment? In the ideal educational environment, students would feel inspired and excited about their contributions to the important research being conducted at the Institute. They would feel connected to the Libin community and confident in their career trajectories.
Dr. Jennifer Thompson, PhD, works with summer student Victoria Palmgren in her lab at UCalgary’s Foothills Campus. Thompson is the Libin’s new education director. What does the Institute offer its trainees? The Libin Institute offers trainees a number of opportunities that foster skills in science communication, critical thinking and networking. Trainees also have the opportunity to be mentored by exceptional scientists within the Institute. For a comprehensive list of what is available, visit libin.ucalgary.ca/research.
What are your goals for education? Moving forward, I would like to see the Libin Institute diversify its training platform to include broader skills training and career planning. I think students and postdoctoral trainees would benefit from gaining awareness of the full breadth of biomedical careers available to them as research trainees.
Why are mentors important? Mentors – both formal and informal – have had a huge impact on my career and life. One of the most impactful influences in my career is a senior principal investigator from Oregon Health and Sciences University, who is one of the most highly respected researchers in my field. He is admired not only for his influential research, but also for his strong mentorship and support of emerging trainees. Although he has no vested interest in my career, he has long been my advocate and has made a tangible impact on my career opportunities.
“Trainees aren’t just driving the research of today, they will be the principal investigators and leaders of tomorrow.” — Dr. Jennifer Thompson
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Rising star By Dawn Smith
Dr. Safia Chatur, MD, (UCalgary ‘14) is grateful for the opportunity to explore and develop a variety of interests while training at the Libin Cardiovascular Institute. A third-year cardiology resident with the goal of further specializing in heart failure, Chatur’s goals don’t end with completing her clinical specialization. She is also keenly interested in including a large research component to her career. Chatur’s main research interest is in cardiovascular outcomes research, which uses big data and statistical analysis to improve the efficiency and effectiveness of health-care systems, but she is also highly interested in incorporating gender and sex considerations into her research. Chatur, who was born and raised in Vancouver, is quick to credit her mentors at the Libin Institute for inspiring her to dream big when considering her future. “My mentors have hugely impacted the trajectory of my training and future career goals,” says Chatur. “I have had so many opportunities to explore things beyond clinical care.”
within the Faculty of Medicine at the University of Calgary is instrumental to trainee success. She is very thankful for her mentors—who are themselves clinicians and academics—who have shared their time, knowledge and experience with her.
Dr. Safia Chatur, MD
Chatur says a number of individuals, such as Drs. Debra Isaac, MD, Stephen Wilton, MD, Aleem Bharwani, MD, Satish Raj, Robert Sheldon, MD, and Todd Anderson, MD, have gone above and beyond in mentoring her.
Chatur is impressed by the supportiveness of the Libin Institute’s cardiology program, led by Dr. Katherine Kavanagh, MD.
Mentorship has its own rewards, and Raj has enjoyed working with Chatur, whom he describes as keenly intelligent with an unsurpassed work ethic.
“Dr. Kavanagh is a fantastic advocate for trainees,” says Chatur. “She recognizes her trainees’s individual interests and provides the latitude and mentorship to cultivate those pursuits.” Chatur notes that the uniquely strong culture of mentorship
“The opportunity to work with [Chatur] reassures me about the future of cardiology,” says Raj. “[Chatur], and trainees like her, are going to be discovering the advances in cardiology for decades to come.”
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Chatur has flourished under the mentorship she has experienced at the Libin Institute. In 2019, she received an honourable mention at the Young Investigator Award Competition in Outcomes Research at the American College of Cardiology Conference for her research examining the cost effectiveness of cardiac devices in patients with left ventricular assist devices (LVADs). She was also the first author in a study published in May 2019 in the Journal of the American Heart Association that looked at fainting during pregnancy. The population level study, done under Sheldon’s supervision, was the first of its kind in this demographic, and revealed that fainting, a fairly common occurrence during pregnancy, is worse than previously assumed. “It was surprising to learn that there are higher rates of preterm birth for moms who have fainted during pregnancy and
increased congenital abnormalities in the babies,” noted Chatur of the findings. “For moms, there is also an increase in syncope and cardiac arrhythmias for the year following birth.” The study sparked a new interest for Chatur, who is now passionate about including sex and gender considerations in her research. It is an area that is surprisingly understudied, as traditionally many research studies have focused on males. For Chatur, considering the biological differences between males and females, as well as how cultural differences impact cardiovascular health, is a necessary step in treating patients effectively. “As a woman and cardiology trainee, these issues are close to my heart,” says Chatur. “We are in an era of precision medicine, where we are looking at individual variables like genes and environment. In order to optimize care equitably, we need to zoom out and take a pluralistic approach to medicine, and that involves consideration of factors like sex and gender.”
Chatur is now a member of the public engagement advisory panel for the Libin Institute’s Women’s Cardiovascular Research Initiative, CV&Me, a new, multi-discipline collaboration of researchers with the mission of optimal cardiovascular health for women in southern Alberta and beyond. Her role in CV&Me is to help make recommendations on strategic and research priorities in the area of heart rhythm as part of a public engagement advisory panel. “It is a fantastic opportunity for a trainee,” says Chatur, adding she is thrilled to help decide strategic and research priorities in the area of cardiac rhythm as part of the panel. Chatur has been accepted into Harvard Medical School’s Advanced Heart Failure and Transplant Fellowship Program, where she will be continuing her training.
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Nurturing talent
Dr. John Tyberg praised for his commitment to students By Dawn Smith
O
n the wall of one of the oldest labs at UCalgary’s Foothills Campus hangs a banner beautifully scripted in Chinese characters. Translated, the Chinese proverb reads “the peaches and plums that you have nurtured are everywhere.” It is a fitting tribute to the career of Dr. John Tyberg, MD, PhD. Tyberg, 81, was a young scientist with a focus on cardiovascular mechanics and dynamics when he started his lab at the University of Calgary in 1981.
Thirty-eight years later, that lab— one of only a handful in the world that investigate the cardiovascular system according to engineering principles—is still producing results. Tyberg’s research interests are varied, but generally focus on topics that have a tangible impact on patients. “I am interested in today’s problems,” he says. Tyberg’s is a well-known name in the field, due to his contributions in the areas of pericardial interaction,
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Dr. John Tyberg, MD, PhD, poses in his lab with trainee Dr. Maryell Urroz, MD, and his longtime lab manager and friend Cheryl Hall.
cardiac pulmonary function and his wave reservoir theory. Although Tyberg is part of an elite group of world-class investigators, the soft-spoken scientist doesn’t have an ounce of arrogance. What does stand out is his genuine interest in others. The warmth of community surrounds you the minute you step into Tyberg’s lab, immediately easing the concerns of the day. Tyberg’s community started small with just a handful of researchers, but now includes scholars, clinicians and colleagues from around the world. The commonality is that each person has had the good fortune to work with Tyberg in some capacity. “He is one of the most intelligent and kind-hearted people that I know,” says Cheryl Hall, who started working with Tyberg in 1982 and is now his lab manager. “He’s genuinely interested in the people in the lab and their families and what is going on with them. We’re family.” The lab photos – taken almost every year for the last 38 - that line the wall of the lab feature the other members of Tyberg’s lab family: the 29 students who have trained in the lab over the years. Many of those trainees have gone onto successful careers as physicians, researchers and academics.
“I still have contact with most of these people,” says Tyberg of the individuals in the photos, which show the progression of time through the changing faces, many of which appear year after year. “I consider a great many of them as personal friends.” Dr. Carol Kroeker, PhD, an adjunct professor in the Dept. of Physiology and Pharmacology, knows firsthand what a wonderful mentor Tyberg is. She completed her doctoral and postdoctoral studies with him and can’t say enough about her mentor’s kindness, flexibility and ability to motivate. “It’s really hard to describe what Dr. John Tyberg did for me,” she says. “I don’t think I would be where I am today if it wasn’t for him, and I don’t think I would be the teacher I am today if he hadn’t shown me how to treat students. If I could inspire even one student the way John inspired me, I would feel like a success.” Dr. Nairne Scott-Douglas, MD, PhD, was a young football player with an interest in science when he came to study in the Tyberg lab. Today, he is the Senior Medical Director of the Alberta Health Services Kidney Health Strategic Clinical Network, the Medical Director of the Southern Alberta Renal Program and head of the Division of Nephrology.
He attributes much of his success to Tyberg, noting the man “imparts far much more than knowledge to people.” “I got into medical school because of him. I could afford to go to school because of him,” Scott-Douglas says of his mentor. “Throughout medical school his support was still there. He was interested in my world.” A unique perspective to problems, approachability and genuine interest are common themes that emerge when speaking with Tyberg’s colleagues, friends and former trainees. Tyberg also feels what he calls the “intrinsic benefits” to mentoring. “I feel a great sense of pride when I think of these people,” he says. “It has been a rewarding experience.”
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Awards and Accolades Dr. Hude Quan, PhD
received a prestigious Killam Annual Professor Award for excellence in teaching.
Dr. Todd Anderson, MD
stepped down from his role as director of the Libin Institute and was appointed vice dean of the Cumming School of Medicine.
Dr. Cvetan Trpkov, MD
is a sixth-year cardiology resident at the Cumming School of Medicine. He placed first in the CCTN/CHFS Research Competition at the 2019 Canadian Cardiovascular Congress, the largest conference for heart specialists in the country.
Dr. Sarah Childs, PhD
was appointed department head of the Faculty of Biochemistry and Molecular Biology.
Dr. Jordan Squair, PhD
was named a 2019 Killam Laureate for his spinal cord stimulation project focused on the cardiovascular health of spinal cord injured patients. Squair is a postdoctoral fellow in the lab of Dr. Aaron Phillips, PhD.
CV&Me
the Libin Institute's sex and gender research collaborative, won a Diversity, Equity and Inclusion award in the team category. The awards are presented by UCalgary's Office of Professionalism, Equity and Diversity.
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Dr. Brenda Hemmelgarn, MD, PhD was appointed dean of the Faculty of Medicine & Dentistry at the University of Alberta.
Institute Researchers
collectively received $3.95M in CIHR project funding during the spring 2019 funding round. Libin boasted a 42 per cent success rate, far above the national average of 15.6 per cent.
Dr. S.R. Wayne Chen, PhD
was co-lead for a research project that revealed how a tiny molecule, calmodulin, modulates the cardiac ryanodine receptor, the heart’s calcium gateway. The resulting article was published in the prestigious journal Nature.
Dr. Derek Chew, MD
is a cardiologist who specializes in heart rhythm issues, who received a $140,000 Banting Scholarship from the Canadian Institutes of Health Research. He will use the funding to continue training in health economics.
Dr. James White MD, PhD received an ASTech award in the category of health innovations for his development and commercialization of software that enables precision healthcare delivery in cardiovascular diagnostics.
Dr. Sofia Ahmed, MD
was appointed the vice chair of research for the Department of Medicine at the Cumming School of Medicine.
Dr. Ed O’Brien, MD
was featured during the coveted Late Breaking Science sessions at the European Society of Cardiology (ESC) Congress—the largest cardiology conference in the world. He shared his work on HSP27, a protein that offers hope to post-menopausal women concerned about their cardiovascular health.
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Thinking outside the box
Drug offers hope for heart failure patients By Dawn Smith
H
eart failure is a serious diagnosis that impacts more than 600,000 Canadians and costs the health care system $600 million annually. One in five Canadians will be diagnosed with the condition in their lifetime, and as a result, will have numerous symptoms, such as extreme fatigue, weakness, shortness of breath, swelling and a reduced ability to exercise. Half of all heart failure patients will die within five years of their diagnosis.
One in five Canadians will be diagnosed with heart failure during their lifetime. Half will die within five years of their diagnosis.
And the burden of heart failure is growing, with costs due to heart failure projected to double by 2030. But researchers are working to improve the quality of life for these patients and decrease the impact of the condition on the health care system. Dr. Jonathan Howlett, a physicianresearcher who focuses on heart failure, is the Canadian lead for an international study that discovered a new use for an existing drug. The study involved more than 4,700 heart failure patients in more than 100 centres around the world and was published in the New England Journal of Medicine – the top medical journal in the world—in September 2019.
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Researchers found that Dapagliflozin, a drug approved for the treatment of diabetes, helps heart failure patients with reduced ejection fraction (HFrEF) by prolonging life, improving quality of life and reducing the length and number of hospital stays. In these patients, the left side of the heart doesn’t pump blood out of the heart efficiently, often due to damage caused by a heart attack. As a result, the volume of blood that is pumped out of the heart with each beat is less than is needed for the body to function properly. Howlett is pleased that the prestigious journal recognized the importance of the international study.
He is optimistic about the new use for the old drug. “It is very gratifying and also reflects the importance of this work,” says Howlett, a physician-researcher within the Libin Cardiovascular Institute. He added he is now using the drug to treat patients who have both diabetes and heart failure. Howlett said physicians now have several tools to help them treat the growing number of heart failure patients, including new medications and devices. He is optimistic about the future for these patients. Howlett is the director of the Heart Failure clinics at Calgary’s Foothills Medical Centre and South Health Campus.
Although heart failure is a serious diagnosis, there is hope. Thanks to the dedication of researchers, physicians now have several tools to help treat heart failure patients, including new medications and devices. Researcher and physician Dr. Jonathan Howlett, MD, is one of the individuals working on developing new treatments for heart failure patients.
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Mind matters
Institute addressing the mental health needs of patients with implanted cardiac devices
By Dawn Smith
I
n 2018, two weeks after receiving a cardiac defibrillator to treat his atrial fibrillation, David Hunt, 78, was doing spring cleanup in his yard. Spying some gravel lying in the grass, he let his shovel head rest against the ground and bent down to pick up the small rocks. At that moment, he felt a jolt rip through his body as his defibrillator
shocked his heart back into rhythm. The sensation sent him staggering to his deck and calling for his wife.
off. Ultimately, it changed Hunt’s life.
“I felt like it blew my head off,” says Hunt. “It went through my nose, ears and head.”
Fearing a repeat, he stopped doing some of the things he enjoyed, like gardening and using his truck and trailer, because he felt the risk of another shock was too high.
Although the shock likely saved his life, the physical trauma caused anxiety, heightened by the fact that there were no warning signs before the defibrillator went
“I started to evaluate the activities I enjoyed and think ‘I can’t do these things,’” he says. “It really affected my quality of life and my ability to enjoy life.”
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Hunt’s experience is not uncommon. Vikas Kuriachan, a cardiologist and the medical director of cardiac implantable electronic devices in Calgary, says patients have described the shocks generated by their defibrillator device as feeling “similar to being kicked in the chest by a horse.”
a third of patients who have a heart attack become depressed, making them twice as likely to die of a subsequent cardiac event within five years.
The event featured Dr. Samuel Sears, PhD, a US-based clinical psychologist and internationally recognized expert on the care of patients with ICD devices.
Raj, who is married to a cardiologist, says the loss of a sense of control
“I had a lot of ‘aha’ moments while listening to Dr. Sam Sears’s presentation,” said Hunt, whose heart is now in rhythm.
The pain and unpredictable nature of the shock can cause mental health concerns, including anxiety, depression and even implantable cardioverterdefibrillator (ICD) shock syndrome, a type of post-traumatic stress disorder that is unique to people with devices.
His biggest takeaway was that his ICD is more likely to be triggered by inactivity. Hunt now offers the following advice to other patients. “Continue living your life and do the things you enjoy doing,” he says. He also encourages patients to seek the help they need. “If I had heard this talk earlier, it would have made a world of difference,” says Hunt.
“It’s a big deal,” says Kuriachan, noting the Calgary team implants more than 1,200 devices each year, including around 350 defibrillators. Dr. Vidya Raj is a psychiatrist who specializes in helping heart patients at the Hearts and Minds Clinic at South Health Campus, which is open to all cardiac patients and accessible through a referral by a practitioner in Cardiac Sciences. Raj, who opened the Calgary clinic three years ago, says mental health concerns for cardiac patients can range from mild anxiety and depression to ICD shock syndrome. She notes all cardiac patients may struggle to come to terms with their life-threatening health concerns and the associated lifestyle changes. These problems with mental health can have a devastating impact. “Patients with mental health concerns are three times less likely to adhere with care recommendations,” said Raj, adding depressed and anxious patients often fail to adhere to their medication or make critical lifestyle changes, such as exercising and eating healthy. These concerns aren’t unique to patients with devices. According to Raj, about
For more information and access to Dr. Sam Sears’s presentation, visit https:// libin.ucalgary.ca/dr-sam-sears.
highly increases risk of anxiety and depression. She added it isn’t uncommon for ICD post traumatic stress disorder patients to become isolated. “I see a lot of suffering,” she says. “At the worst stages, you want to stop going out, stop going on holidays and are afraid to drive. You get this avoidance phenomenon.” Raj says timely, responsive mental health support can make a huge difference. Hunt agrees. Although he is more than happy with the care he received, he didn’t receive mental health support following his shock. After suffering for more than a year, he attended a presentation, hosted by the Libin Cardiovascular Institute, that changed his outlook.
Another helpful resource for ICD patients and their families and friends is the ICD patient support group, which meets at Foothills Medical Centre four to five times per year. For more information or to join, email Paul Mercer at mercerpaul@shaw. ca or by telephone at 403.944.1248 and ask for Sandra or Allana.
“It really affected my quality of life and my ability to enjoy life.” — David Hunt, patient
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Taking it to the next level
Cardiac surgeon uses innovative techniques to improve patient experience By Dawn Smith
I
t has been couple of tough years for Al Cheney, 75. The retired oil and gas worker’s quality of life plummeted since suffering a massive heart attack in 2017. Suffering with symptoms such as an irregular heart beat, swelling and difficulty breathing that made mobility difficult, Cheney was diagnosed with heart failure following the heart attack. He has spent a great deal of time in the hospital – often weeks at a time. Although Cheney’s life improved somewhat after treatment, doctors determined he needed an implantable defibrillator with a special pacemaker lead to help improve his heart function. Cheney received the defibrillator, protecting him from dangerous heart rhythms. However, his cardiac resynchronization therapy implant procedure— which involves adding a pacing lead through the coronary sinus, a special vein in the heart—was not successful because of the anatomy of his heart.
“I was fortunate to have access to the right technology at our institution, which allows us to be innovative.” — Dr. Jacques Rizkallah, MD
However, in August 2019, Cheney’s physician, Dr. Jacques Rizkallah, MD, a young
cardiologist who began working in Calgary in 2016, was able to overcome this using a novel technique known as Left Bundle pacing. It was the first time that this surgical technique was performed in Canada. Rizkallah, who received specialized training at Harvard Medical School, explains that in standard pacemaker implant procedures, doctors insert one or more pacemaker wires into the heart to activate it based on the specific needs of the patient condition. Although the purpose of a pacemaker is to treat patients with slow heart rates, in some rare cases, activating the heart with the pacemaker can cause it to enlarge and weaken. Known as pacemaker mediated cardiomyopathy, the condition is caused by activation of the heart out of sync. In the new approach, also referred to as physiologic pacing, the pacing wire is implanted in a specific part of the heart along its normal conduction system, reducing the risk of pacemaker mediated cardiomyopathy and treating heart failure in some cases. “This allows us to stimulate and activate the heart with the pacemaker the way it is naturally designed to be activated,” says Rizkallah.
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Although fluoroscopy-free ablations are performed at many centres in Canada, Rizkallah is employing it for complex procedures, such as those that require the atrial septum of the heart to be punctured to treat arrhythmias like atrial fibrillation. The approach uses ultrasound imaging within the heart as a guide, a method that is performed at just a few of the largest hospitals in Canada. The zero-fluoroscopy ultrasound guided technique has only been around for a couple of years and is harder to learn and implement. “The first case was a little nerve wracking, but exciting,” says Rizkallah. “I was fortunate to have access to the right technology at our institution, which allows us to be innovative.” Rizkallah says his colleagues are also keen on learning the new method. Cardiologist Dr. Jacques Rizkallah was the first in Calgary to perform radiation-free ablations during complex surgeries. He also introduced HIS Bundle and Left Bundle pacing techniques. There are two surgical techniques involved in physiologic pacing: His bundle pacing and left bundle pacing. His bundle pacing places the pacemaker lead closer to the centre of the heart’s conduction system along the ventricular septum. Left Bundle pacing positions the lead in a deeper, specific location in the heart muscle that is more challenging to reach but provides a good alternative for patients in whom the HIS Bundle location isn’t technically feasible.
patients benefit with improvements in their heart function,” he says.
Radiation free ablation Rizkallah was also the first in Western Canada—and amongst the first in Canada— to perform a radiation-free complex ablation, a procedure that uses special catheters to burn or freeze circuits in the heart that cause abnormal rhythms.
“Everything is better,” he said. “I have nothing but good things to say about that surgery.”
The majority of physicians rely on fluoroscopy using X-rays to visualize their tools in the heart when performing complex ablations, but this standard procedure has a potentially serious drawback. Both patients and physicians are exposed to radiation, with the amount dependent on the length of the procedure.
Although the HIS bundle and Left Bundle pacing techniques are more technically challenging and require more time to perform than the standard pacing methods, Rizkallah is pleased with the results.
Over time, the cumulative exposure increases the risk of cancer for health care providers. To shield themselves and reduce radiation exposure, physicians wear a cumbersome, lead apron weighing about 30 pounds while performing ablations.
“Persevering through these surgeries is very rewarding when we see
Not using fluoroscopy during ablations avoids all of those complications, explains Rizkallah.
Cheney notes there was significant improvement in his quality of life after the left bundle pacing procedure.
“I work with a great group of colleagues that are always looking to adopt innovative ways to deliver the best care to our patients.”
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Putting patients first Nurse practitioner-led cardiac unit amongst first in Canada By Dawn Smith
T
here were some exciting changes to the medical cardiology coronary care unit (CCU) at Calgary’s Rocky View General (RGH) hospital in 2019. On February 1, 2019, the seven-bed unit, which treats patients admitted with heart problems, became one of the first in Canada to be led by nurse practitioners, health-care leaders with advanced training in nursing. Nurse practitioner Nancy Clark, who spearheaded the initiative and is now the clinic nurse practitioner lead for the clinic, says the model provides consistent care for patients, as there is now a dedicated team of professionals on hand with advanced knowledge in cardiology and the ability to diagnose and prescribe medication. “We are the first in line to consult with the emergency room on cardiology matters,”
she says. “We are available for all hours, covering all shifts. We see all patients.” Rocky View’s cardiology program is one of the busiest in Calgary. The hospital has a 35-bed cardiology ward and seven-bed CCU. Prior to the change, it operated like most across the country, although it did have support from nurse practitioners, including Clark. But when the nurse practitioners weren’t on shift, the unit was dependent on extenders and clinical assistants to cover the load. These clinicians came and went, covering shifts in hospitals around the city. According to Teresa Thurber, the executive director of critical care and women’s health at RGH, although care was excellent, it was difficult to ensure there was consistency and aroundthe-clock expertise for patients.
This new model has solved these issues. Eight nurse practitioners with specialized training in cardiology look after the unit. There is always one, and often two, of these highly educated professionals on duty. They work in conjunction with a consulting cardiologist to ensure the critically ill patients have what they need. These professionals are responsible for the first line of care in the unit doing everything from assessments and urgent bedside consults to diagnostics and treatments. The nurse practitioners are also the first point of contact between the emergency department and the unit and provide cardiology consults for the emergency team. “This creates consistency and continuity in coverage,” says Thurber, noting despite the fact that the supporting
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The medical cardiology coronary care unit at Calgary’s Rocky View General hospital is one of the first nurse practitioner-led units in Canada. These health care providers have advanced nursing training. Pictured at back (left to right) are nurse practitioners Daniel Ward, Margaret Henninger, Mohamed El Hussein, Karen Parker and Adrienne Rommens. Front (left to right): Nancy Clark, Mikaela Robertson, Jen Koppel and Lisa Wieler. cardiologist on the unit changes weekly, there are now professionals in place who “know the patients really well.”
lead of cardiology at RGH, agrees and notes that nurse practitioners bring a holistic approach to patient care.
Thurber says although data is preliminary, she expects it to show that patients are having better experiences and outcomes within the unit. She is confident there will be a reduction in length of stay and readmission rates for patients. Thurber is impressed with the nurse practitioners’ commitment and passion to the model.
“There is improvement in patient care. They have gone above and beyond,” he says. “They bring a whole different angle to patient care. It was the right thing to do to have nurse practitioners in more of a leadership role.”
“We have an exceptionally wonderful group,” she says. “When we talk about putting our patients first, these providers are truly committed to doing that. They follow their patients from the emergency department to CCU or the ward and even into the community.” Dr. Nakul Sharma, who has worked alongside the nurse practitioners as the
Members of the CCU hope the model will be expanded to others centres. To that end, Clark said the nurse practitioners are working on a research project with plans to publish in a peer-reviewed journal. The research project will include both data and the patient voice. Sharma says the next steps are to expand the model in Calgary and to train the health care professionals to do simple invasive tasks.
Thurber is fully supportive. “I hope this is just the beginning for nurse practitioners,” she says. “They are a very skilled, dedicated group of practitioners.” Nurse practitioners began working in cardiac surgery in Calgary in 2002. Their leadership expanded to medical cardiology in 2003. Clark was the lone nurse practitioner in cardiology for several years. Thanks in part to her leadership, leaders within the Department of Cardiac Sciences at the Cumming School of Medicine and at RGH recognized the benefit that nurse practitioners bring and supported the groundbreaking initiative at the CCU.
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Imaging centre celebrating 15 years Ken Stephenson’s foundational gift continues to help shape landscape of cardiac care within the Libin Institute By Steve Macfarlane, Cumming School of Medicine
I
t didn’t take long to convince Ken Stephenson that creating a home in Calgary for cardiovascular imaging was a worthwhile undertaking. The instant the shrewd Calgary businessman saw the image of a beating human heart projected on a highresolution screen, he was hooked. And for the 15 years since that fateful meeting at the Calgary Petroleum Club with cardiologist and cardiac magneetic resonance imaging visionary Dr. Neil Filipchuk, MD, fellow philanthropist Bud McCaig, and Eva Friesen of the Calgary Health Trust, Stephenson has been a key piece of the beating heart behind the Stephenson Cardiac Imaging Centre at Foothills Medical Centre in partnership with the Cumming School of Medicine and Alberta Health Services. “I see this beating heart and I just loved it. Even as a layman I could understand what I was seeing. Seeing the heart beating, it just resonated with me,” says Stephenson in his downtown office, where the philanthropist and entrepreneur continues to work passionately at age 86. “I could see on that screen that day
what the possibilities were. And so I decided right then I was going to do it. I was going to raise the money needed.”
critical contribution to the success of the Centre. I am most grateful for the wonderful contributions of our team.”
Generously contributing $1 million of his own funds as a foundational gift to build the Centre back in March of 2005, Stephenson was just as important as a fundraiser — bringing in another $2M from friends and associates and $1M from the Foothills Foundation Lottery on the recommendation of Dr. Chen Fong, MD. Support from the community has exceeded more than $8M since the Centre’s opening, and Stephenson just recently donated another $1M through UCalgary to the Centre bearing his name.
Those working at the Centre are equally appreciative of the support.
“I am proud that, together with the wonderful support of my donors, I have been able to keep the Centre financed with philanthropy over 15 years,” says Stephenson. “The Centre’s great success would not be possible without the outstanding capabilities and dedication of the Centre’s researchers, clinicians and support staff, all under the extremely capable direction of Dr. James White, the Director of the Centre. James makes things happen, a
“I am grateful to Ken Stephenson for redefining my perspectives on giving, and how it can achieve large-scale and sustained impact,” says Dr. White. “Over the years, Ken’s generosity and passion have seeded scientific discoveries, catalyzed innovation and enabled great ideas to grow into global success stories.” The first program of its kind in Canada, the Stephenson Centre as part of the Libin Cardiovascular Institute established Cardiac MRI as a pillar of cardiac care in southern Alberta. Over the last decade and a half, it has grown into one of the most innovative environments for translational clinical research, the training of physicians and researchers and delivering worldclass imaging services in Calgary. “The Stephenson Centre is a shining example of what is possible through partnership between philanthropic
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Calgary businessman Ken Stephenson (centre) is the naming donor of the Stephenson Cardiac Imaging Centre within the Libin Cardiovascular Institute. The centre performs thousands of routine cardiac imaging tests each year and is an internationally recognized centre for research. You too can partner with the University of Calgary to spark meaningful change. Together, we are creating the future of health in Calgary and beyond. Visit libin.ucalgary.ca/giving.
individuals, the university and the health authority,” says Dr. Todd Anderson, MD, former director of the Libin Cardiovascular Institute. “The success of the Centre over the past 15 years is astounding and has been catalyzed by the ongoing dedication that Mr. Stephenson brings to the project. He is a pillar of our society and a great friend to myself and the entire medical community.” With a satellite at the South Health Campus, the Centre performs nearly 4,000 cardiac MRI studies each year in addition to research studies and collaborations in Alberta and around the world. Experts are influencing therapy in patients with early heart disease, guiding imaging in routine patient care and are now poised toward predicting and preventing sudden cardiac death in those with heart rhythm defects. “We’re in a whole new era of diagnostics,” says Stephenson, a hint of both excitement and pride in his voice as he talks about the Centre’s work in improving quality of life for people with cardiovascular issues. “We’re going to be able to, with more
research, predict heart failure, sudden death and atrial fibrillation. We can be more prepared for what’s coming.”
White, Stephenson is better equipped to talk with fellow philanthropists on the needs of the Centre and its future.
The future of imaging lies in more personalized medicine that includes genomics and proteomics — the study of genes and the proteins in cells — and data that, through machine learning, can lead to predictors of disease and distress in patients.
“You have to understand what you’re raising money for, and really have your heart and soul in it. I have, for 15 years,” says Stephenson. “I just feel very responsible for the Centre and want it to continue to be successful in providing leading edge diagnostics to its patients and beyond.”
“The promise of the Libin Institute to lead the world in precision cardiovascular medicine will be achieved by integrating the incredible potential of the Stephenson Centre with our world-class clinicians. The Stephenson Centre is the cornerstone of our vision for the future of precision cardiovascular health,” says Dr. Paul Fedak, director of the Libin Institute. If Stephenson were to have the same meeting at the Petroleum Club today, the screen would show much more than the beating heart, it would provide a plethora of information not imagined in 2004. Making every effort to truly understand the complicated work that took place under the leadership of original director Dr. Matthias Friedrich and now
Its success, by all measurements, is evidenced by the care people in Calgary receive — made possible by the great clinicians and scientists who collaborate at the Centre. “His support has allowed the Stephenson Cardiac Imaging Centre to become the largest of its kind in North America. This has enabled unprecedented care for Albertans and growth of an innovative research program focused on personalized medicine,” says White. “I consider Ken to be a pioneer in the philanthropic community who uniquely demonstrates how investing emotionally can dramatically amplify the impact of investing financially.”
libin@ucalgary.ca
@LibinInstitute @LibinInstituteAB
