HEART FAILURE AND HEART TRANSPLANT CENTRE ANNUAL REPORT 2001-2002 PREPARED BY: Dr. Nadia Giannetti Medical Director and Dr. Renzo Cecere Surgical Director Mandate The McGill University Health Centre Heart Failure and Heart Transplant Centre in its current configuration was founded in February 2000. It is located at the Royal Victoria Hospital in the E pavillion. The mandate of the Centre is to provide a multi-disciplinary approach to optimize care for heart transplant, heart failure and mechanical cardiac assist patients and to provide cutting- edge medical and surgical therapy to this population. The Centre serves as a back-drop for innovative research and teaching for patients, residents and colleagues. It serves as drop-in Centre for patients with acute medical problems with the intention of decreasing emergency room visits. Patients Patients followed at the Centre include heart failure, heart transplant and mechnical assist device patients. Patients either present at scheduled visits or can present without appointments Monday to Friday from 8:30 AM to 4:00 PM. Those who are acutely ill can receive intravenous perfusions in the Centre thus bypassing the emergency room. Over the past year, there were 3262 patient visits. This was an increase of 17% over 2000-2001. There are over 400 heart failure patients currently followed at the Centre and 150 heart transplant patients. At any one time, there are 5-7 mechanical assist device patients followed. Staff The clinic is staffed with a medical secretary and ward clerk. There are 3 full-time nurse coordinators and 1 half-time coordinator. The coordinators share call such that someone is on call 7 days a week and 24 hours a day. This allows rapid access to care for ailing patients and ensures that donor hearts get rapidly processed. There is also one full-time research nurse coordinator in the Centre. The medical staff includes Dr. Giannetti who sees patients in the clinic 5 days a week and Dr. Cecere who evaluates both scheduled and unscheduled patients weekly. Dr. Elstein and Dr. Brophy , both in the division of cardiology, assess patients in the clinic one half day per month. Dr. Cantarovich, a member of the division of transplantation, sees heart transplant patients concurrently with Dr. Giannetti 1 to 2 half days per week. Dr. Kimoff, a member of the division of respirology, with an interest in sleep apnea and heart failure follows patients with heart failure and pulmonary problems in the Centre twice per month. On a weekly basis, Sonia Page, a dietician with an interest in heart failure assesses patients in the clinic. Cases The following is a list of patients who received heart transplantation or mechanical circulatory support from April 1, 2001-March 31, 2002 Transplants April 01, 2001 – March 31, 2002 Initials Age Transplant surgeon Outcome TR (on VAD pre- 14 R. Cecere Alive and well transplant) AR 51 R. Cecere Alive and well CD (on VAD pre- 32 R. Cecere Alive and well transplant) RD 55 R. Cecere Alive and well JF (on VAD pre- 60 R. Cecere Alive and well transplant) GZ 37 R. Cecere Alive and well SO (HEART AND 38 R. Cecere Alive and well LUNG) RS 60 R. Cecere Alive and well CM 58 R. Cecere Alive and well VL 7 R. Cecere Alive and well JP 67 R. Cecere Alive and well AD (HEART AND 19 R. Cecere Deceased: multi-organ failure LUNG) Mechanical Circulatory Support April 01, 2001 – March 31, 2002 Initials Age Sex Where from Surgeon Outcome CD 31 M LAKESHORE R. Cecere TRANSPLANTED JF 60 M HALIFAX R. Cecere TRANSPLANTED AE 62 M RVH R.Cecere DIED OF CVA EJ 2 M MCH R. Cecere/C. TRANSPLANTED Tchervenkov MB 47 M RVH R. Cecere DIED OF MULIT-ORGAN FAILURE RC 37 M QUEBEC CITY R. Cecere D/C HOME ON LVAD SN 42 F RVH B. D/C HOME ON LVAD DeVarennes/R. Cecere * RN 58 M RVH R. Cecere D/C HOME ON LVAD DD 61 M CHARLES R.Cecere D/C HOME ON LVAD LEMOYNE GM 61 M INSTITUE DE R.Cecere D/C HOME ON LVAD CARDIOLOGIE * Post-cardiotomy failure to ween from heart-lung bypass Teaching/supervision Cardiology fellows see patient in the Centre during non-invasive rotation (2 half days per week). A number of residents in internal medicine have rotated through the clinic as part of an elective. These have included Drs. Maggie Nguyen and Angeline Law from the MGH and Dr. Jean- Francois Dorval from the RVH. There has been supervision of fellows for research projects. This has included Dr. Dominique Joyal who presented a poster at the Canadian Society of Transplantation conference in February 2002. “Low dose daclizumab post-cardiac transplantation. Also, cardiology fellow Dr. Regina Husa presented an oral abstract at the International Society of Heart and Lung Transplantation conference, April 2002: “Acute heart transplant rejection associated with late steroid withdrawal.” Dr. Cecere has established Novacor and Thoratec training programs at the MUHC. Through these three days programs, teams of clinicians receive theoretical and practical instruction on the use of ventricular assist devices. Practice implants are performed on a unique swine model at the animal facilities of the Montreal General Hospital site. This year, groups from Halifax and Quebec City were trained. Conferences and Presentations Dr. N. Giannetti March 22, 2001: McGill University Continuing medical education conference (Thursday evening lecture series) “Heart failure in the elderly” April 22, 2001: Association des Medecins Haitien du Quebec. Continuing education. “Heart Failure Therapy” May 3, 2001: McGill University continuing education drug therapy course. “Heart Failure drugs” May 10, 2001: Medical Grand-Rounds at St. Mary’s Hospital. “Chronic heart failure: advances in therapy.” September 2001: Primary panelist for Canadian consensus guidelines on Cardiac Transplantation. Presented at the Canadian Cardiovascular Society meeting 2001, Halifax. September 2001: Invited expert panelist at the Canadian Cardiovascular Society meeting 2001, Halifax. For session on “New Therapies in Heart Failure” chaired by Dr. Peter Liu and Dr. Malcolm Arnold. September 29, 2001: Association des cardiologues du Quebec. “Heart failure in the Elderly.” Mont Tremblant October 5, 2001: Symposium on Heart Failure and Transplantation. “Heart failure: Diagnosis, management and treatment” Royal Victoria Hospital October 19, 2001: Cardiology nursing symposium. “Heart Failure Treatment”. Montreal General Hospital February 12th, 2002: Canadian Cardiovascular Society winter symposium. “When pills aren’t enough: Surgical Therapy for Heart Failure”. Mexico. February 27th, 2002: Cardiac Society of Transplantation , Sangstat fellows work-shop. “Updates in cardiac transplantation”. Mont-Tremblant, Quebec. March 24, 2002: New Horizons in Heart Failure Symposium. “Refractory Heart Failure”. Chanteclerc , Quebec Dr. R. Cecere March 24, 2002: New Horizons in Heart Failure Symposium. “Surgical Therapy for Heart Failure”. Chanteclerc , Quebec March 2002: International Society for Heart and Lung Transplantation: Symposium on INTREPID “The role of destination LVAD therapy”. Washington DC. Communications Dr. N. Giannetti March 12th , 2002. Global television. Interview with Stuart Greer, the use of mechanical assist devices for long-term therapy. March 21st , 2002. TVA. Live television interview with Jocelyne Cazin in television show “Dans Lamire” on organ donor awareness. April 16, 2002. Live radio interview on CJAD radio with Tommy Schnurmacher. “Organ Donation. “ Dr. R. Cecere March 12th , 2002. Global television. Interview with Stuart Greer, the use of mechanical assist devices for long-term therapy. March 2002: The Gazette interview and feature on the use of LVADs as destination therapy March 2002: Feature on “Your Health” show with host Dini Petty, LVADs Research Funding and studies: Non-industry funding and studies: 1999-2001: Deane Nesbitt Award (Internal scholarship from the Montreal General Hospital Research Institute) Awarded to Dr. Nadia Giannetti for research in heart failure $ 10 000.00 per year x 3 year 2000-2001: The Gustav Levinski Foundation Awards Sonia Page and Dr. N. Giannetti. For research in nutritional therapy for heart failure $ 8597.00 2001: CIHR operating grant Dr. M. Goldberg and Dr. N. Giannetti The short-term effects of ambient air pollution on clinical signs and symptoms for congestive heart failure: A pilot study $66,490 2001: CIHR multi-centre study Atrial Fibrillation in Congestive Heart Failure Dr. N. Giannetti, Local principal investigator 2000: Mayo Clinic Foundation Giant cell myocarditis treatment trial and registry Dr. N. Giannetti, Local principal investigator Industry funded studies 2000-2002: Candasartan in heart failure assessment of reduction in mortality and morbidity. (CHARM). Sponsored by Astra Pharmaceuticals Dr. N. Giannetti, Local principal investigator 2000-2002: Omepatrilat versus enalapril randomized trial of utility in reducing events in heart failure (OVERTURE). Sponsored by Bristol -Myers-Squibb Dr. N. Giannetti, Local principal investigator 2000-2001: A Randomized Comparative Trial of Prograf versus Neoral in the treatment of hyperlipidemia one year after heart transplantation. Dr. N. Giannetti, Local principal investigator and member of steering committee. 2000-2001: Randomized double-blind multi-center study of the efficacy and safety of valganciclvir vs. oral ganciclovir formthe prevention of cytomegalovirus disease in high-risk heart allograft recipients. Sponsored by Roche Dr. N. Giannetti, Local co-investigator 2000-2001: Biventricular pacing in heart failure (MIRACLE sub-study) Dr. R. Cecere, Local principal investigator Dr. N. Giannetti, Local co-investigator 2001: Cardiac support device trial (ACORN) sponsored by Acorn cardiovascular inc. Dr. R. Cecere, Local principal investigator Dr. N. Giannetti, Local co-investigator 2002: INTrEPID trial. Investigation of Non-Transplant-Eligible Patients who are Inotrope Dependant. (Novacor Left Ventricular Assist Device as destination therapy). Sponsored by Worldheart inc. Dr. R. Cecere, Local principal investigator Dr. N. Giannetti, Local co-investigator Publications: Chan MC, Giannetti N, Kato T, Kornbluth M, Oyer P, Valantine HA, Robbins RC, Hunt SA. Severe tricuspid regurgitation after heart transplantation. J Heart Lung Transplant. 2001 Jul;20(7):709-17. Montoya JG, Giraldo LF, Efron B, Stinson EB, Gamberg P, Hunt S, Giannetti N, Miller J, Remington JS. Infectious Complications among 620 Consecutive Heart Transplant Patients at Stanford University Medical Center. Clin Infect Dis. 2001 Sep 1;33(5):629-640. Giannetti N, Management of congestive heart failure: how well are we doing? CMAJ. 2001 Aug 7;165(3):305-6. Giannetti N, Heridity N, Alimollah A.,Gao S.Z., Shroeder J.S., Hunt SA, Valantine HA. Mild hyperhomocysteinemia is not associated with cardiac allograft coronary disease. Clinical Transplantation 2001;15(4):247-252 Cantarovich M, Metrakos P, Giannetti N, Cecere R, Barkun J, Tchervenkov J. Anti-CD25 monoclonal antibody coverage allows for calcineurin inhibitor "holiday" in solid organ transplant patients with acute renal dysfunction1. Transplantation 2002 Apr 15;73(7):1169-1172 Cantin B, Giannetti N, Parekh H, Panchal SN, Kwok BW, Najem R, Woodman K, Hunt SA, Valantine HA. Mycophenolic acid concentrations in long-term heart transplant patients: relationship with calcineurin antagonists and acute rejection. Clin Transplant. 2002 Jun;16(3):196-201. Ross H, Hendry P, Dipchand A, Giannetti N, hirsh G, Isaac D, Singh N, West L, White M. Canadia Cardiovascular Society Consensus Conference on Cardiac Transplantation. www.ccs.ca (oct. 2001) Abstracts: M. Cantarovich, N. Giannetti, J. Barkun. Royal Victoria Hospital, McGill University Health Center,Montreal, Quebec, Canada. Neoral dose monitoring with Cyclosporine 2-hour post-dose levels results in a clinical benefit compared to trough levels in stable heart transplant patients. Oral presentation at the International Congress of the Transplantation Society; Rome, August 2000. N. Giannetti, G. Bal, R. Cecere, M. Cantarovich. Late steroid withdrawal in post-heart transplant patients is associated with a risk of significant rejection. Presented at the Canadian Society of Transplantation meeting in Lake Louise in 2001. Cantarovich M, Giannetti N, Cyr E, Chartier R, Cecere R. Improvement of acute renal dysfunction in heart transplant patients during calcineurin inhibitor 'holiday' without rejection under anti-CD25 monoclonal antibody coverage.J Heart Lung Transplant. 2001;20(2):233. Cantarovich M, Cyr E, Chartier R, Giannetti N, Cecere R.Correlation between the glomerular filtratiion rate, serum creatinine, creatinine clearance and the calculated creatinine clearance in heart transplant patients. J Heart Lung Transplant. 2001 ;20(2):205-206. Cecere R, Ergina P, De Varennes B, Lachapelle K, Giannetti N. Single centre experience with pulsatile mechanical bridging to heart transplantation. The Canadian Journal of Cardiology 2001; 17 (Suppl C): 168C. Cecere R, Giannetti N. Reducton annuloplasty and alfieri repair in the treatment of severe dilated cardiomyopathy: Sustained improvement in clinical variable.The Canadian Journal of Cardiology 2001 ; 17 (Suppl C): 200C. Cantarovich M, Giannetti N, Cecere R. Relationship between endomyocardial biopsy score and cyclosporin 2-hour peak levels during the first year after heart transplantation. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Cecere R, Giannetti N. Reduction Annuloplasty and alfieri repair in the treatment of severe dilated cardiomyopathy: Early improvement in clinical variables. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Cecere R, Ergina P, Lachapelle K, de Varennes B, Giannetti N. Successful outpatient management of Novacor and Thoratec VAD patients. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Cecere R, de Varennes B, Ergina P, Lachapelle K, Giannetti N. Biventricular mechanical support and heart transplantation for anthracycline cardiomyopathy in a child. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Cecere R, Ergina P, Lachapelle K, de Varennes B, Giannetti N. A bridge-to-a-bridge: using short- term mechanical circulatory support as a selection criterionfor long-term bridging to heart transplantation. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Joyal D, Cecere R, Cantarovich M, Giannetti N. Early experience with low dose daclizumab for the prevention of acute rejection in cardiac transplantation. Abstract presentation at the Canadian Society of Transplantation meeting, spring 2002. Husa R, Cecere R, Cantarovich M, Giannetti N. Acute heart transplant rejection associated with late steroid withdrawal. Journal Heart Lung Transplant 2002 Jan; 21(1):167 Future Directions Having demonstrated the viability of the bridge-to-transplant concept with favorable results, we believe it is appropriate at this time to offer mechanical assist services to a much broader patient base. Our intent is to develop a network whereby non-transplant cardiac centers can request mechanical support for their most critical or unstable patients with the option of subsequent transfer and management at out Centre. This hub-and-spoke paradigm has proven to be effective at several hub-centres throughout the United States. In addition, we have been approached to participate in several upcoming clinical trials to evaluate novel surgical procedures and devices aimed at heart failure patients. Due to the large volume of patients seen in our Heart Failure and Transplant Centre staffed by highly skilled and motivated individuals, we remain very attractive as a site for carrying out basic and clinical research.