SATURDAY SECTION M Peter Munk - University Health · PDF filePeter Munk Cardiac Centre ......

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M2⎮TORONTO STAR SATURDAY, JANUARY 31, 2015 ON ON1

PETER MUNK CARDIAC CENTRE

One snowy morning at a GoodLifeFitness centre, David Hawkins, 62, isquietly lifting weights with his per-sonal trainer. They chat about theexercises: what they’re working on,how it should feel. There is no goad-ing, no bulging veins, no sweat-soaked triumphant grunts.

While many of us still think of gymssimply as spaces for voraciously un-doing holiday excesses, this workoutdemonstrates what fitness shouldbe: accessible, possible and beneficialfor everyone — especially for thepeople for whom working out is liter-ally do or die.

When Paul Oh, medical director ofthe University Health Network(UHN) cardiovascular preventionand rehabilitation program says topatients, “Congratulations, you’vehad a heart attack,” he’s not beingfacetious.

“It’s a real wake-up call,” he says.“It’s a chance to finally learn how tolive healthier.”

The problem though, is that whilethis wake-up call prompts most pa-tients to initially adhere to their doc-tor-ordered lifestyle changes, morethan half of those patients stop exer-cising at around the one-year post-incident mark.

Solution? The cardiac-care expertsat Peter Munk Cardiac Centre(PMCC) and the fitness pros at GoodLife have teamed up to create afirst-of-its-kind program to meet theneeds of patients completing theirfour- to six-month cardiac rehab.

It’s the most recent program from apartnership that began with theGoodLife Fitness Centre of Excel-lence in Cardiovascular Rehabilita-tion Medicine, a state-of-the-art re-hab facility. Now that GoodLife isoffering a free three-month mem-bership to all of the rehab’s gradu-ates, they want to see just what canhappen next.

For Hawkins, a bike-commuter and

all-around fit guy, the onset of shoul-der pain and arm fatigue five yearsago sent him to physio, not the emer-gency room. Puzzled physiothera-pists, unable to calm what wasthought to be a pinched nerve, sentHawkins to his family doctor. Anelectrocardiogram (ECG) led to astress echo, which led to an angio-gram where stents were placed toalleviate arterial blockages.

“They put in the stents and the nextday I was sent home,” he says. Heknew exercise was an important partof his getting better, but a frozenshoulder got in the way. Then helearned about the rehab program atUHN.

For Hawkins, it meant two sessionsa week, 45 minutes to an hour each,for several months, using the tread-mill, recumbent bike and hand bike.

“At every session, there’s a numberof attendants — including kinesiol-ogists and nurses. They take yourresting heart rate and blood pressureas you begin, halfway through yourroutine and again at the end.”

That’s part of his routine now withJonathon Joaquim, one of 18 special-

ly trained GoodLife trainers part ofthe program.

The transition from UHN patientto GoodLife client is engineered to beas smooth as possible — from makingsure the equipment in both facilitiesis the same and having the trainersgo through an orientation sessionand shadowing the rehab specialists,to understanding the unique needsof heart patients and looking forwarning signs like profuse sweating,light-headedness and breathlessnessthat might indicate they are workingthe heart too hard.

“Very few of my clients want to getjacked,” says Joaquim. “They justwant to have a normal life. Theymight be battling cancer or have hy-

pertension or high stress. It’s a way tomanage their lives. Exercise is a greatsolution. This sort of training is bet-ter than any prescription.”

This passionate belief that exercisedoes more than just make us lookgood in bathing suits is what broughtGoodLife on board in the first place.

“I get hit up quite a bit,” says David“Patch” Patchell-Evans, GoodLifefounder and CEO. “When I was con-tacted by the Peter Munk Centre, Itold them I could only do it at nine ona Tuesday night. They said yes. Andwhen I walked in, all the key doctorswere there — 20 expensive chief car-diac doctors. That impressed me. Imade the emotional decision thatnight to commit.”

GoodLife teams up with doctors for heart health

David Hawkins, right, talks with personal trainer Jonathon Joaquim as part of a joint venture between GoodLife and the Peter Munk Cardiac Centre.

One-of-a-kind program helpsrecovering cardiac patientskeep up with exercise regime

KATE RAESPECIAL TO THE STAR

“Exercise is a great solution. This sort of training is betterthan any prescription.”JONATHON JOAQUIMGOODLIFE TRAINER

> FITNESS REHAB

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ON ON1 SATURDAY, JANUARY 31, 2015 TORONTO STAR⎮M3


Just 200 metres from the summit ofAntarctica’s highest mountain,something went wrong.

Two members of the Canadianclimbing team felt their legs growstrangely heavy. Their movementsslowed dramatically. They tried eat-ing energy bars, hoping they werejust low on calories, but nothinghelped.

By the time they turned back tocamp, things got worse.

One woman began vomiting, hadtrouble breathing and her oxygenlevels dropped to dangerously lowlevels. She had high-altitude pulmo-nary edema, a life-threatening con-dition involving fluid filling the lungs.

It feels similar to heart failure —ironically.

The victim was Dr. Heather Ross, aworld-renowned cardiologist andmedical director of the heart trans-plant program at Toronto’s PeterMunk Cardiac Centre. The 2006Vinson Massif climb was part of afundraising campaign for heart fail-ure research, called Test Your Limits,which she spearheaded.

The 52-year-old survived, making itoff the mountain after a 15 hour-plusordeal involving a plane and skiingdown the mountain, but the experi-ence changed her.

“I can’t quite talk about it withoutgetting fairly emotional,” Ross told aStar reporter in November, sitting ina Toronto General Hospital (TGH)Starbucks with tears in her eyes.

“Feeling as short of breath as I didand knowing that my patients feelthat every day . . . It gave me an ideaof what it is like to wait and notknow,” she said.

Eight years on, Ross can be foundhigh-fiving patients in the TGHheart function clinic, cracking jokesand sternly scolding a patient who’sneglected to take her medication.

“She’s a no-nonsense doctor . . . butshe’s really easy to talk to,” says pa-tient Maureen Wellington, 55. “You

can see her as a person, not just assomeone who’s taking care of yourdisease.”

Ross is busy — she’ll see 23 patientsbefore noon — but she doesn’t let herpatients know it.

Wearing a well-tailored light greysuit and gold jewelry, Ross walks intoeach appointment and sits down ateye level with her patients. She restsher elbows on her knees and leans in.

“What you have is what I do,” shetells a 22-year-old with an unknownheart problem.

The woman plays nervously withher hair and her voice shakes whenshe asks questions. Her eyes stayglued on Ross.

By the end of the appointment, herteary-eyed mom is laughing and her

dad says, “That is one great doctor.”Ross hopes her compassion and

ability to connect with patients im-proved after the Vinson Massif scare.

“I like to think I go that extra step ortake the extra time,” she said. “Andgive the information in a straight andhonest way . . . (and help patients)recognize that we’re going throughthis as a team, together.”

She treats patients how she wouldwant to be treated, she says.

Throughout the morning shift,Ross adjusted her tone, stance andhumour for each of her 23 patients,depending on their age (patients in-clude teenagers and 80-somethings),severity of diagnosis and relation-ship.

“Do you feel adequately chastised?”she teased one patient.

“I’m a bit worried, I have to be hon-est with you,” she said, deadpan, toanother.

The changing bedside manner isstrategic. “You use the humour andthen you talk about the seriousness,”she said between appointments.“Whether it’s the 2-year-old or the82-year-old, find some common

ground to connect.” But Ross’s refusal to “disconnect”

from patients can take a toll. “That’s where the exercise comes

in,” she said. Ross cycles, swims, hikes and goes

on jaw-dropping, globetrotting ad-ventures. In 2006, she launched theTest Your Limits campaign — thereason for the Antarctica trip.

Along with a team of doctors andtransplant patients, Ross hasclimbed in Nepal, trekked in Bhutanand skied in the North and SouthPole, raising nearly $2 million forheart failure research.

To relax, Ross visits her cottage inLake of Bays, indulges in Toronto’s“foodie” scene and sings in a band.

But most of the time, she’s wakingup around 5 a.m., working non-stopand grabbing power bars for lunchbecause morning and afternoonclinics overlap. She typically works 12hours straight. Back in the clinic,Ross doesn’t mince words whendealing with a complicated case.

“She has the unfortunate honour ofbeing interesting, which of course isnever what you want to be (in) medi-

cine,” she says, turning to the patientand adding, “I don’t know why youhave this.”

It’s these mystery cases that keepRoss excited — waking her up at 2a.m., she says.

“It’s so unsatisfying when we can’tanswer the ‘why,’ ” she says.

Ross’s near-death experience hasshaped her professional interests,which focus on keeping patientsalive and comfortable. Her main re-search is on prognosis — predictingheart problems for patients — andimproving quality of life.

She thinks back on the difficult dayin Antarctica often, but there’s oneparticular moment — involving herclimbing teammate and formerheart transplant patient, Dale Ship-pam — that she’ll never forget.

“I remember very clearly looking atDale and seeing that look in his eyesof, ‘You know, you saved my life andI’m here to help save your life,’ ” shesays, choking back tears as she re-members him helping her climbdown the mountain.

“It was just a really incredible mo-ment.”

> WALKING THE TALK

Doctor hopes near-death disaster made her even betterSurviving a health crisis hashelped Heather Ross bringmore compassion to her care

KATRINA CLARKE STAFF REPORTER

Former heart transplant patient Dale Shippam, centre, with Dr. HeatherRoss, right, at the North Pole. The climb was part of a fundraising drive.

World-renowned cardiologist Dr. Heather Ross reviews patient records. Shealters her tone and humour for each patient she sees.

BERNARD WEIL/TORONTO STAR

“She’s a no-nonsense doctor . . .You can see her as a person, not just as someone who’staking care of your disease.”MAUREEN WELLINGTONPATIENT OF DR. HEATHER ROSS

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Kimberly, 27, never thought shewould be facing open-heart surgeryat such a young age. But, last year, anechocardiogram revealed a tear inher aorta known as a Type A dis-section, which has a mortality rate of1 per cent per hour in the first twodays without treatment after diagno-sis.

Kimberly (not her real name) wasimmediately wheeled into an oper-ating room at the Peter Munk Cardi-ac Centre (PMCC). “I was crying andpanicking,” says Kimberly, “but Iknew I would die without the sur-gery.”

Kimberly has familial thoracic aor-tic aneurysm and dissection, a genet-ic mutation that runs in her mother’sside of the family. Because the opera-tion involved removing part of theaorta that was weakened by her ge-netic disease, her cardiac surgeon,Maral Ouzounian, was able to en-courage Kimberly to donate the tis-sue to the Peter Munk Cardiac Cen-tre Cardiovascular Biobank.

“I did it to help people my age with asimilar genetic condition, my rela-tives and maybe someday, my kids,”says Kimberly, who recently gotmarried.

The biobank is a national, anony-mous, systematic and organizedstorage facility, which has been col-lecting and freezing tissue and bloodsamples from surgical patients withheart disease for three years. To date,2,000 individuals who have under-

gone surgery for aortic dissections,valve replacements and device im-plants, among others, have partici-pated.

The goal of the PMCC biobank is toestablish biomarkers — a measur-able genetic substance that indicatesthe presence of disease — that mayhelp researchers understand howheart disease progresses, how totreat it and how to predict who maydevelop the disease in the future,says Phyllis Billia, co-director of thebiobank.

“We hope to expand our blood sam-ple collection to all patients who en-ter the centre with heart disease, notjust for surgery,” she explains.

The ultimate goal is to personalizecare to each individual patient.While each sample collected is anon-ymous, the sample will include thepatient’s medical history detailingmedications, surgeries, routineblood tests and medical examina-tions. That way, the biobank will helpresearchers better understand varia-tions in genes that may, for example,predict which patient will be respon-

sive to medication. “We know that some patients are

sensitive to Aspirin, while others areresistant,” says Billia. “It would behelpful to know this ahead of time toprevent dangerous side effects frommedication or find other drugs thatmay work better for a patient.”

Finding an effective treatment forcardiomyopathy, a heart-muscle dis-ease “that runs in families and cancause sudden death,” would be an-other example of a significant find-ing, says Billia.

One of the most successful out-comes of biobank screening is thediscovery of Herceptin, an antibodythat targets cell receptors in certainbreast cancers. Researchers then de-veloped a drug using the Herceptinantibody that is now being used totreat women with HER-2 positivebreast cancers, which has increasedsurvival rates.

The hope is that the PMCC biobankwill yield therapeutic and drug dis-coveries for heart disease as well.

“If we know what causes these dis-sections,” says Ouzounian, “we canhopefully target genes or moleculesthat can prevent or slow down theprogression.”

Ultimately, she adds, the goal is tohelp people like Kimberly avoid aor-tic surgery in the future.

In Kimberly’s case, she would havelikely faced sudden death if the echo-cardiogram hadn’t revealed her aor-tic tear.

“I had no symptoms, but I do knowthat my grandfather died suddenly.My mother has gone through twosimilar surgeries in her lifetime. So Iknow I was extremely fortunate tohave the outcome that I did.”

> GENETIC DISCOVERIES

From left, surgeons Dr. Richard Weisel, Dr. Maral Ouzounian and Dr. Phyllis Billia examining tissue samples.THOMAS BOLLMANN PHOTOS

Better understandingof diseases could be just a biobank awayTissue, blood donations from more than 2,000 heart patientswill help establish genetic markers and lead to medication

Laura Tumiati, left, a PMCC nurse receives a tissue sample from Dr. Maral Ouzounian.

“If we know what causes thesedissections, we can hopefullytarget genes or molecules that can prevent or slow downthe progression.” DR. MARAL OUZOUNIANCARDIAC SURGEON

JUNE ROGERSSPECIAL TO THE STAR

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This advertisement is for informational purposes only.® Registered trademark of Royal Bank of Canada. Used under license.© Copyright 2015. All rights reserved.

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RBC is proud to support the PeterMunk Cardiac Centre and theirdedication to providing world-class,cardiovascular care for patients acrossCanada. Treating over 55,000 peopleeach year, the Centre is globallyrecognized for cardiac education,research and innovation.

A Proud Supporter of thePeter Munk Cardiac Centre

How PMCC is managing high-riskarrhythmia in pregnant women

Pregnant women worry aboutmany things: the health of theirbabies, the pain of labour, theresponsibilities of motherhood.And for some mothers-to-be, thatworry list includes their hearts.

“A lot of arrhythmias are mani-fested only in pregnancy,” says Dr.Danna Spears, cardiac electro-physiologist at PMCC, who worksclosely with the centre’s maternal-fetal medicine group. “This is oftendue to the change in blood volumeor hormonal changes associatedwith pregnancy. We don’t un-derstand it completely.”

What they do know is that be-tween 60 and 70 per cent ofpregnant women experience somekind of heart palpitations duringpregnancy and merit an investiga-tion. Of those, about one-fifthhave extra beats or true arrhyth-mia.

“The good news,” says Spears, “isthe vast majority can be managedwith conservative measures.” Thatmanagement can be as non-interfering as learning mental andphysical methods to reduce anxi-ety. And, explains Spears, “chanc-es are, after the pregnancy, theirhearts will return to normal.”

For those rare pregnant womenwith more extreme arrhythmia,the news is also good. As Spearsexplains, it used to be that suchwomen risked a 50-per-cent mor-tality rate, so their choices were toabort, deliver early or undergoradiation — a route with its ownset of risks. Now those high-riskarrhythmia cases can be managedmedically or with catheter ablationwith no radiation exposure.

Spears credits these advances —as well as leading-edge work inmanaging fetal arrhythmia — topartnerships the PMCC has withmaternal fetal medicine and high-risk obstetrics at Mount SinaiHospital, and the fetal cardiacprogram at the Hospital for SickChildren.

“We have a very unique situationat PMCC,” she says. One thatmeans safer pregnancies andbetter outcomes.

Geri Morey and her husband, Jeff,were awakened in the middle of thenight with news that is every parent’snightmare: Their 21-year-old daugh-ter Nicole had been found dead inher bed in her residence room at theUniversity of Guelph.

An autopsy later showed no appar-ent reason for her death; her hearthad simply stopped.

That was in 2003, and the Peterbor-ough, Ont., mother had her suspi-cions about what killed her daughter— suspicions based on at least two generations worth of health his-tory.

“When I was in Grade 7, I had ahandful of fainting spells, and thatcontinued until I was 21 and diag-nosed with epilepsy,” says Morey.“When I was 11, my mother, who was32 at the time, died in her sleep.” Hermother, Morey says, had been in per-fect health, but did suffer from faint-ing spells.

When, at age 14, Nicole started hav-ing fainting spells, Morey took ac-tion.

“She had all kinds of medical testsdone,” says Morey.

“They sent her for EEGs on herhead, they sent her for blood tests,urine tests and when everything wasnegative, they sent us to do the sametests over again.” Nicole had alsoseen a cardiologist, who had the teenwear an electronic halter for a week-end to monitor her heart.

“But the result at that time, theytold us, was negative — there wasnothing there,” says Morey.

Some 18 months after Nicole died,Morey’s younger daughter, Jennifer,started fainting. Morey’s family doc-tor had retired and Jennifer was re-ferred to Dr. Michael Gollob, a spe-cialist in sudden cardiac death (SCD)in young people at the Peter MunkCardiac Centre (PMCC) in Toronto.

Gollob’s testing revealed Jenniferwas borderline for long QT syn-drome, a condition that impacts theheart’s electrical ability to pump, cre-ating a risk of dangerous arrhythmia(irregular or abnormal heartbeat)and sudden death. And because peo-ple with this condition have normalheart structures, explains Gollob, anautopsy will not reveal any heartproblems.

Morey says when she showed Gol-lob the printout from Nicole’s halterheart monitor test, “it blatantlyshowed that Nicole had had long QTsyndrome.”

Long QT syndrome, explains Gol-lob, is just one of the causes of SCD inthe young, a tragedy that strikes 30 to50 Ontario families every year.

“I personally see about two familiesamonth who have lost a child and areseeking answers and clinical evalua-tion,” says Gollob.

Those evaluations are designed toreveal whether a person’s arrhyth-mia is due to structural issues, suchas hypertrophic cardiomyopathy,where the heart muscle thickensdangerously, or conditions, such aslong QT, which Gollob describes aspurely electrical.

“We had all the red flags and nodoctor questioned it,” says Morey.“No one discussed that with us. Ikept saying, ‘This is strange becausemy mother had nothing and she diedin her sleep. I was diagnosed withepilepsy and my daughter died in hersleep,’ but they didn’t connect thedots.”

But at the PMCC, Gollob did con-nect those dots. He had the Morey’sextended family undergo genetictesting, and while the results re-vealed that Jennifer did not havelong QT syndrome, Morey herselfdid.

“For over 30 years, I took the wrongmedication,” she says.

After the correct diagnosis at

PMCC, Morey was put on a betablocker. She is grateful to have an-swers, and at age 63, she is trying toraise awareness about SCD in theyoung and the life-saving work atPMCC.

“I have to do that for Nicole,” shesays. “As parents, my husband and Iboth needed answers.”

The PMCC is at the forefront of

clinical care and research innova-tion, says Gollob.

“The PMCC has the largest inher-ited arrhythmia clinical and researchprogram in Canada and is dedicatedto advancing the knowledge and carein their field,” he says.

And as Morey knows, it’s the kind ofcare that can make all the differencein people’s lives.

Connecting the dotson irregular heart Motivated by her daughter’s unexpected passing, a motherraises awareness about sudden cardiac death in young people

JACQUELINE KOVACSSPECIAL TO THE STAR

> PERSONAL TRAGEDY> PROTECTING THE

MOST VULNERABLE

Geri Morey holds up a photograph of her daughter, Nicole, who died at just21 years old of sudden cardiac death caused by Long QT syndrome, whichPMCC determined runs in Morey’s family.

WAYNE EARDLEY FOR THE TORONTO STAR



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In a small boardroom at the PeterMunk Cardiac Centre, eight mem-bers of the hospital’s innovationcommittee are hotly debating thepros and cons of a seemingly crazyidea: Would recovering heart pa-tients be more likely to stick withtheir prescribed exercise regimen ifthey were given a dollar a day?

The proposal to investigate the an-swer (one of five before the panelthat’s been dubbed the Dragon’s Denof medicine) is being examined by aseemingly disparate crew that in-cludes real estate developers, a radi-ologist, a former investment bankerand a nurse practitioner.

Thanks to cuts in governmentfunding, an aging population, ascramble to keep up with moderntechnology and crumbling infra-structure, there’s currently a wholelot of “no” in health care.

This small but vocal group (thereare 13 on the committee in total)wants to say “yes” — to ideas, to pos-sibilities, to the power of apple skins,green dye and customized mice cre-ated in a lab in Maine.

Formed two years ago by chair Har-ry Rakowski, the committee (“defi-nitely the most functional one I haveever been a part of,” confesses onemember), has $1 million a year todistribute to pioneers at the centre.

“Hospitals have difficulty in under-standing what innovation is and fos-tering it and funding it,” Rakowskisays. “The Peter Munk Cardiac Cen-tre didn’t have a mechanism in placeto critically appraise proposals andunderstand whether they wereworth funding, their sustainabilityand how it would lead to both animprovement in patient care and al-so to funding down the road.”

The makeup of members is in itselfinnovative: business gurus and med-ical experts rub shoulders, bouncingideas off one another, giving everyproject a critical eye from all differ-ent angles.

“Not funding innovation,” says Ra-kowski, “is like not funding researchand development at a corporation.”

So far, about 60 per cent of theproposals have received approval,with around 30 projects now in vari-ous stages. Rakowski vets all of theprojects in advance, offering sugges-tions to help them get approved.

One “great win” has already made abig impact at the centre, reducingblood consumption in the operatingroom by 40 per cent thanks to amachine that evaluates a patient’sblood’s ability to coagulate.

But back to the Dragons’ Den. Lin-da Belford, a nurse practitioner, isarguing passionately in favour of theproposal to use cash rewards to in-centivize exercise. Of course itsounds strange, she argues, but thefact is that nothing else seems to beworking.

“The benefits of cardiac rehabilita-tion are real, but the continuance ofthe program afterwards is poor,” Bel-ford argues. “Eighty per cent of pa-tients don’t continue with exerciseprograms after rehab.” Although sherecognized this might not be the so-lution to getting people healthier,Belford wanted to try it anyway.

Other committee members dis-agree just as vehemently, citing prob-lems with everything from opticsand sustainability to the cost of theproject (its researchers were re-questing $150,000, over a tenth of thecommittee’s annual budget).

Rakowski’s difficulty with the ideaboils down to this: “If you can’t bemotivated by the fact that you mightdie, seven bucks a week isn’t going todo it.”

The proposal gets rejected, after afive-to-three vote, as does anotherfor a spiritual care app that was citedas vague, costly (at $250,000) andpoorly designed.

But there is much excitementabout other proposals, including anupdate from committee memberKeiran Murphy, a radiologist, abouthis own recently funded $50,000

project to explore how a simple anti-oxidant cocktail containing vitaminC, omegas 3, 6 and 9 and an appleskin extraction can prevent DNAdamage caused by diagnostic radia-tion.

It’s a simple and accessible poten-tial solution that can be used by ev-eryone from people concernedabout bone scans and dental X-raysto frequent flyers (airline pilots areshown to have a greater rate of genet-

ic translocation than people whowork for airlines that don’t leave theground).

Another proposal that has the com-mittee excited is a study of how agreen injectable dye can help cardio-vascular patients with poor circula-tion in their lower extremities at riskof losing a limb. It’s the project’s thirdkick at the can, having gone backtwice for revisions. This time, thegroup is unanimous in its support.

There’s also a proposal to studywhether the use of two types of anti-diabetic drugs can prevent abdomi-nal aortic aneurysms using specifi-cally designed mice from a lab inMaine.

The group agrees that it’s a longshot, but with 5 per cent of men over65 walking around with an undiag-nosed aneurysm at risk of rupturing,the implications if it does work arehuge.

“You have to throw a lot of darts at aproblem before you hit the target,”says Rakowski.

The fifth and final proposal of theday is to follow up with adults withonly one ventricle (most of us havetwo) who underwent a Fontan pro-cedure as children to shunt the ma-jor vein from the abdomen up to theveins going to the lungs. The down-side of this life-saving operation isthat most patients go on to developliver abnormalities.

Murphy (jokingly referred to byRakowski as his “I-like-everythingguy”) encourages the committee tosupport the proposal, the first step,he hopes, in helping to improve theprocedure.

“We wouldn’t invent anything newif we say it’s good enough. Manytimes in medicine we decide it’s asgood as it’s going to get. I think weshould look at this and ask, ‘How canthis be done better?’ ” The groupfinally agrees it will go back for revi-sions.

That feeling — that “what if it doeswork?” — is at the heart of the com-mittee’s mandate. It’s what has driv-en medicine forward for centuries,and what will propel it into the fu-ture.

“The innovation we help foster to-day will become tomorrow’s prac-tice,” says Rakowski. “We just have tobe willing to take chances.”

Why the ‘Dragon’s Den’ of medicine is on fireMany of the PMCC’s innovation committee initiativeshave paid dividends, going on to receive government funding

KATE RAESPECIAL TO THE STAR

Ali Ursani, left, team leader in medical imaging service, and Dr. NarinderPaul look through a cardiovascular phantom, the result of an innovationinitiative. The device mimics heartbeats in rate and rhythm to facilitateultralow doses of X-ray radiation during CT studies of the heart.

TIM FRASER FOR THE TORONTO STAR

“Not funding innovation is likenot funding research anddevelopment at a corporation.”HARRY RAKOWSKIINNOVATION COMMITTEECHAIRMAN

> BREAKING THROUGH

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It’s a complex case. The patient has bladder cancer.He also has a narrowed heart valve, cardiac calcifica-tion, a stent and a pacemaker. He’s taking a bloodthinner. Then there’s his abdominal aneurysm.

The cancer needs to be operated on as soon aspossible, but the cardiac stress the surgery wouldcause could prove fatal. So a multidisciplinary team ofdoctors from the Peter Munk Cardiac Centre(PMCC) has decided to start the patient’s treatmentby mending his weak heart.

“The University Health Network is all about treatingthe person who has nowhere else to turn,” veterancardiac surgeon Dr. R.J. Cusimano says.

Part of Toronto’s University Health Network(UHN), the PMCC is using multidisciplinary medicalteams to tackle Canada’s most complex cardiac cases.Groups of up to a dozen medical staff can tend to asingle patient, sharing knowledge and expertise gar-nered from their respective fields to enhance patientcare and treat multi-faceted medical issues.

“We believe that patients are best served in a team-based approach and that’s how we try and managepatients — especially when we are using newer, morecomplicated technologies,” Dr. Barry Rubin, thePMCC’s chair and medical director, says.

“When you have multiple different perspectives, wealso think that gives you a better opportunity to beable to solve the problems that you run into, andindeed to plan to try and avoid those problems.”

Multidisciplinary medical teams meet weekly at thePMCC to discuss cases. In this one, doctors decidedon a transcatheter aortic valve implantation (or “TA-

VI”): a non-invasive surgical technique forhigh-risk patients in need of aortic valvereplacements.

While TAVI procedures are usually per-formed through an artery in the groin, thispatient’s abdominal aneurysm and nar-rowed blood vessels would make that diffi-cult.

The patient’s coronary arteries, more-over, are abnormally close to the problem-atic valve and the new valve could inadver-tently cause pre-existing calcification inthe patient’s heart to block those arteriesand send him into cardiac arrest.

So, the medical team has decided to startwith a bypass as a fail-safe. To avoid theaneurysm and narrowed blood vessels,they will operate from the tip of the pa-tient’s heart via an incision in the side of hischest.

“Rather than having a cardiologist orheart surgeon do this on their own, we putthe two together,” Rubin says of TAVI pro-cedures.

“They see it from different perspectives.The heart surgeon is used to sorting thingsout through an incision; the cardiologist isused to sorting things out without makingan incision — so the two of them cometogether using advanced imaging equip-ment in the operating room.”

Cusimano is working with cardiologistsDr. Eric Horlick and Dr. Mark Osten on thiscase. Cusimano is an expert at operating

through tricky incisions; Horlick and Ostenare experts at non-invasive techniques,such as TAVI.

“We take the skills of multiple people anduse them on patients with complex prob-lems,” Horlick says. “In the past, patientslike this would get morphine and an apol-ogy.”

The operating room is awash in fluores-cent and LED lights. It’s a hive of activity:rushing, buzzing, busy hands and beeps asmore than a dozen medical staff tend to thepatient, ready equipment and monitor in-struments and screens. Everyone wearsscrubs, masks, hairnets and lead vests thatrun from their necks to their knees to pro-tect them from X-ray radiation.

The patient lies prostrate on the operat-ing table. His heart can just be seen beatingthrough an opening in his exposed ribs.He’s already been connected to a heart-lung machine that can provide life supportin the event of an emergency and a secondpacemaker has been placed in his chest toalter the pace of his heart during differentstages of the surgery. A suction tube evencollects spilled blood that is recycled via acell saver machine for later use.

After the bypass comes the crucial valvereplacement. From the apex of the heart,one of the cardiologists manually feeds in aguidewire.

The doctors watch everything they do onmonitors, displaying images from an ultra-

sound probe placed down the patient’sesophagus, and an X-ray machine that hasbeen placed over the operating table. Thedoctors occasionally ask technicians to in-ject dye into the patient’s bloodstream dur-ing crucial stages of the surgery to enhanceimage contrast.

Using the guidewire, one of the cardiolo-gists feeds a small balloon into the valve. Inan instant, the heart is stopped and theballoon expands, stretching the narrowedvalve and leaving behind a permanent wirecage and a new valve made from the sack ofa cow’s heart.

The patient’s heart begins beating again.The six-hour operation is a success.

“All that preparation was just for thosefew seconds,” Cusimano says of the TAVIprocedure. “It was truly a team effort.”

For a long time after the procedure, Cusi-mano stands beside the patient, his glovedthumb applying pressure directly to theheart while the nurses and other doctorswrap up their work and disperse.

“If you cut your hand, you put pressure onit to stop bleeding,” he says. “Whether it’syour hand or your heart, it’s the same pro-cess.”

Cusimano looks wistfully at this windowinto his patient’s life.

“I’ve been doing this since 1977 and I stillget a rush out of putting my hand on some-body’s heart,” he says. “It’s something younever get tired of.”

A balloon that will help place the valve, or “TAVI,” in its spot in the heart is tested before being inserted.

A team of doctors performs a minimally invasive surgery to replace a heart valve with X-rays, CT scans and ultrasound.

Dr. R.J. Cusimano, cardiac surgeon, and cardiologist Dr. Mark Osten look at a patient’s heart through a small cut near his ribs.Lights are dimmed so that, from left, Dr. Eric Horlick, Dr. R. J. Cusimano and Dr. Mark Osten can see displays.

Nurses clean equipment for the minimally invasive surgery to replace a heart valve.

An ultrasound probe and X-ray machine over the operating table assist the team.

STEVE RUSSELL PHOTOS/TORONTO STAR

Nurses prep the equipment for surgery. Everyone wears scrubs, masks, hairnets and lead to protect them from X-ray radiation.

“We take theskills of multiplepeople and usethem on patientswith complexproblems. In thepast, patientslike this wouldget morphineand an apology.”DR. ERIC HORLICKCARDIOLOGIST

DANIEL OTIS STAFF REPORTER

A group of multidisciplinary medical doctors work together to solve some of the country’s most complex cardiac cases

The heart of the team

Aortic valve disease (AVD) is a life-threateningcondition that usually kills within two years. Weasked Eric Horlick, a cardiologist and director ofstructural heart disease intervention at thePeter Munk Cardiac Centre about a new pro-gram that ensures patients get prompt care.

What is aortic valve disease? A normal aortic valve is between four to

five centimetres square and all of the bloodthat feeds the body passes through it. Theaverage patient with aortic valve disease hasa narrowed aortic valve, which puts them attremendous risk.

Why? The heart muscle has to work that much

harder to pump blood through the narrowedopening and the increased workload re-quires more blood to nourish the heart.

It significantly affects a person’s ability tofunction. With aortic valve disease, theheart’s flow is capped. Even if the “tap” is onfull tilt, only a trickle of blood flows through.

The heart cannot compensate to meeteveryday needs and the patient suffers ashortness of breath, chest pain, fainting andsudden death.

Who does AVD affect? Aortic stenosis happens in two groups of

patients. The first is patients born with acongenitally abnormal valve. Those valvescan fail in childhood, early adulthood, middleadulthood or by age 60. The other group ofpatients are the elderly — usually 65 and up.There is wear and tear on the valve and itcontinues to degenerate until the valve canno longer open and close. More than one ineight patients aged 75 and older have mod-erate to severe aortic valve stenosis.

Why is it important for these people to beassessed quickly?

The vast majority of AVD patients face anaccess problem. They remain stuck forweeks or months at the family doctor level.They may go on to get the wrong test at thewrong place using the wrong technique.Sometimes patients wait six to eight months

for tests. Although severe AVD is complete-ly treatable in most cases, these patientshave a mortality clock ticking. Once youdevelop symptoms and you are not a candi-date for surgery, your mortality is 60 percent in the first year. You may well die or endup in hospital with heart failure while waitingto see a doctor.

How will the PMCC’s new rapid-assess-ment program speed things up?

Our aortic valve team guarantees anypatient referred by a doctor will be seen byan aortic stenosis expert within 24 hoursand will get expert and timely treatment.

What does treatment involve? The normal treatment for severe aortic

valve disease is surgery — we take out theold aortic valve and sew in a new one. But it’sa serious operation and many patients aretoo sick or frail to survive. For them, we turnto minimally invasive procedures, includingthe transcatheter aortic valve implant (TA-VI). Our team can perform the entire proce-dure in under 30 minutes.

Q&A > DR. ERIC HORLICK

Rapid assessment saves lives for those with aortic valve diseaseCAMILLA CORNELLSPECIAL TO THE STAR

“You may welldie or end up in hospital withheart failurewhile waiting tosee a doctor.”ERIC HORLICKDIRECTOR OFSTRUCTURALHEART DISEASEINTERVENTION AT PMCC



When Linda Goldsack first begancampaigning for donations for thePeter Munk Cardiac Centre (PMCC)in the mid-’90s, she approached ademographic she knew might oneday be most in need of its services —stressed-out stockbrokers and bank-ers whose workplace pressuresmade them vulnerable to heart dis-ease.

“I knocked on every door on BaySt.,” she says. “This is one of the bestcardiac programs in the world and Iknew those guys would want to hearabout it.”

Goldsack, who now chairs thePMCC’s current 10-year, $100-mil-lion campaign, draws on a donor listof 3,800 people, 20 per cent of whomhave given more than $1,000 to thispremier cardiac centre that treats55,000 patients annually. The cam-paign, called Building the Future, ischampioned by board member Jef-frey Rubenstein. Some give substan-tially more than that. Peter and Me-lanie Munk lead the pack and are thecentre’s largest donors with gifts ofalmost $70 million over the past 20years. But there are others who havealso given millions to fund every-thing from medical units and equip-ment to endowments for chairhol-ders, professorships and fellowshipsthat help attract top medical staff.

“The Munks were the ones whogave the centre its profile and raisedthe bar on donations and this en-couraged others to come on board,”says Goldsack. “Philanthropists givebecause they know this centre is sec-ond to none. It attracts the best med-ical professionals who know this is aplace where they can practise theircraft and save lives on a daily basis.”

Joe Burnett is one of those philan-thropists. The 78-year-old chair ofToronto’s Burnac Corporation —specializing in real estate, producedistribution and retail jewelry — has

donated close to $15 million to thePMCC over the past two decades.

“There’s an absolute need for fund-ing in the cardiac area because heartdisease affects so many Canadianwomen and men,” says Burnett.“The cardiac centre is the finest of itskind and I have so much admirationfor the doctors who work there.”

Despite his impressive eight-figuredonation to the PMCC, Burnett,whose estimated worth surpasses $1billion, says the need is so great hefeels he should be increasing his do-nations. “It’s not quite enough mon-ey,” he says. “I could be giving a wholelot more.”

Goldsack describes Burnett as ahands-off donor. “When he makes agift, he will say to the leaders, ‘I’mgoing to give you this money and youdecide how it’s best to be used.’ ”

Other philanthropists prefer to getpersonally involved.

Toronto’s Arnold Irwin, the 88-year-old scion of the Irwin Toy dy-nasty — the Canadian distributor ofsuch popular American toys as theHula Hoop, the Slinky and Easy-Bake-Oven — likes to meet withmedical staff to find out exactly howhis money is being put to use.

“I like to see the money I give go to aparticular researcher or project and Ilike to hear directly from them about

what it is they need,” says Irwin,whose recent donation was used topurchase 3D echocardiography im-aging equipment to establish the firstCanadian anesthesiology cardiovas-cular imaging centre.

“I get such a terrific kick out ofhearing how they were able to usemy money to help their project prog-ress,” says Irwin.

Many among those who give do soin memory of a loved one who died ofheart disease.

Such is the case with Tony LaSorda,an innovator in the marketing ser-vices industry, who died of a rareheart condition in 2011 when he was56 and awaiting a heart transplant.

When he got sick, LaSorda becamea PMCC donor and his family andfriends have continued his giving leg-acy by creating the LaSorda Fellow-ship with a goal of raising $1 millionthrough special events over 10 yearsto fund PMCC fellows — researcherswho play a key role in advancing dis-covery in cardiology by undertakinginnovative projects, the results ofwhich are published in peer-re-viewed journals.

Some $250,000 has already beenraised thanks to two golf tourna-ments and the annual Tony LaSordaSociable, a dinner, dance and silentauction, which also serves to bring

together LaSorda’s family, friendsand industry colleagues.

“Tony was a really giving man, agreat coach and mentor who madepeople believe they could achievewhatever they wanted to achieve,”says Dom Ieraci, his close friend andfinancial adviser. “When he passedaway, a group of us got together todetermine how we could continuehis legacy and continue the work hehad started with the fellowship pro-gram.”

Goldsack says it’s been heartwarm-ing to see the unwavering commit-ment of LaSorda’s family and friendsto honour his memory through phil-anthropic efforts.

“He was so loved and he touched somany lives,” she says. “They want tohonour his memory for as long asthey can.”

While donors are motivated to givefor different reasons, one thing’s forcertain — their dollars make a differ-ence. Goldsack notes that over theyears, charitable contributions to thePMCC have supported such innova-tions as mitral, pulmonary and aorticvalve repair and replacement, whichcost upward of $30,000 each and area less invasive approach to openheart surgery, as well as the introduc-tion of mechanical hearts, which cost$100,000 each and keep people alivewhile they wait for a heart trans-plant.

Goldsack notes both these innova-tions, originally funded by dona-tions, now receive financial supportfrom the Ministry of Health becausethey were proven to be successful.“That’s how philanthropy saveslives,” she says.

Opening up their hearts — and walletsFrom innovative technology to professorships, donationshelp in many different ways

ANNE BOKMASPECIAL TO THE STAR

It’s a 3D experience like no other. The result of a donation from

Toronto’s Arnold Irwin (founder ofIrwin Toy), a 3D echocardiographymachine produces three-dimen-sional images of a cardiac pa-tient’s heart while in surgery.

The images produced are on thesame accuracy level as CT scansand MRIs, explains MassimilianoMeineri, an associate professor ofanesthesiology.

“It used to be that we did echoesthrough the chest wall,” saysMeineri. “These were very low-quality images compared with the3D. We would be looking at 2Dslices rather than the whole heart.”

Now, when the patient is underanesthetic, a probe with specialcamera is inserted down throughthe esophagus.

It then generates images for thesurgeon to see the problem heartwhile it’s beating.

“This confirms the diagnosisbefore the surgeon opens theheart, and better determines thepathology,” Meineri explains, “sothe surgeon can do the best, mostaccurate work for the patients.”

“For the patient,” Meineri says,“we can be more precise, but wecan also do more preservativesurgery — we can fix more valvesrather than replacing them . . .”The 3D echocardiography technol-ogy is used again after surgery,before the patient even leaves theoperating room.

Outside of the operating theatre,this technology has other advan-tages since Irwin’s donation hasmeant PMCC has been able to puttogether the required infrastruc-ture for storing, sharing and ana-lyzing 3D images of normal andpathologic hearts. Indeed, Irwin’sdonation has helped fund thePerioperative 3D TEE AnesthesiaResearch Centre, one of few suchcentres in the world and the firstof its kind in Canada.

> A 3-DIMENSIONALLOOK AT THE HEART

Dr. Massimiliano Meineri, right, tests the 3D echocardiography imagingequipment with Toronto philanthropist Arnold Irwin.

THOMAS BOLLMAN PHOTOS FOR THE TORONTO STAR

The echocardiography model is apart of the Canadian anesthesiologycardiovascular imaging centre.

> LIVE-SAVING PHILANTHROPY

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In April 2005, Sally Fung had justfinished her final exams — she wastired and stressed. Like many under-graduate students, late nights and aquick-energy quick-crash diet werecatching up with the 23-year-old.She had all the signs of a bad cold,maybe even the flu, since the backpain was excruciating.

Shortly after crawling into bed onMay 1, she told her boyfriend (nowhusband) she couldn’t breathe. Heinsisted they go immediately to thelocal hospital’s emergency depart-ment. That decision may have savedFung’s life.

It was 1 a.m. when the couple ar-rived at the hospital and, other thanunusually low blood pressure, Funglooked fine.

“There were hardly any doctorsworking, so they didn’t want to admitme,” she remembers.

Her future husband was persistent,telling medical staff, “She doesn’tlook right, you need to examine her.”

When her blood pressure took an-other plunge, to 60 over 40 (normalis 120 over 80), Fung was admittedand given an electrocardiogram.

Her blood pressure was still drop-ping, but she wasn’t bleeding. She feltnauseous, but had only a small din-ner hours earlier.

“They couldn’t put the pieces to-gether,” says Fung.

There was, however, enough evi-dence to warrant admitting her tointensive care, where she was givenan ultrasound on her stomach. Nodamage, no explanation, nothing.

The doctor told her, “Since we’rehere, I’ll ultrasound your heart, too.”That spur-of-the-moment decisionmay also have been life-saving.

Fung’s heart was swollen. “I’ve never, ever seen such a big

heart,” is what she remembers beingtold.

After that, things moved fast.At 3 a.m., technicians were called in

to perform a CT scan and doctorscompiled all her records and test re-sults. Fung would travel an hour byambulance the next day from Mark-ham Stouffville Hospital to the PeterMunk Cardiac Centre in Torontowhere her records had been sent.

Ask her if she feels that decisionalso saved her life and she says: “It’snot that I feel like they (the PMCC)saved my life. I know they saved mylife.”

Waiting at Markham Stouffville fortransport to Toronto that springnight, Fung had 12 drugs in her IV, sothere was no more pain and she wascalm. “I didn’t know that I should bescared,” she says.

Her mother and boyfriend, howev-er, were fully aware and terrified.

Doctors were concerned Fung’sheart would stop during the ambu-lance ride to Toronto.

That didn’t happen until she ar-

rived at the PMCC. Switching Fung from the ambu-

lance equipment to the hospitalequipment caused her breathing tobecome laboured again.

She remembers asking attendants,“Please put the other oxygen maskback,” and then, “I saw a bright lightand three angels coming to get me.”

Fung was put in a medically indu-ced coma and taken to surgery.

“When she arrived, I was worriedshe wouldn’t make it to the operatingroom in time,” says Fung’s surgeon,Vivek Rao, chief of cardiac surgeryand director of transplant and me-chanical support at PMCC.

When she woke up two weeks later,Fung was covered by a sheet, underwhich her chest was still open, herdamaged heart hooked up to tubesleading to a two-pound BiventricularAssist Device (BiVAD) that sat at herbedside.

Fung had myocarditis, inflamma-tion of the heart caused by autoim-mune disorders, environmental tox-ins or, as in her case, a viral infection.It’s a potentially fatal condition thatinterferes with the heart’s ability topump blood through the body.

Myocarditis is rare — fewer than 10cases per 100,000 people — and usu-ally causes one heart ventricle toshut down. In Fung’s case, both ven-tricles had stopped working; the Bi-VAD was doing all the work.

The hope was that the device wouldtake over for Fung’s heart longenough for the organ to recover andthen work on its own.

The odds were not in her favour. “I had only a 20 per cent chance of

keeping my own heart,” she says.That’s why her name was also put onthe transplant list. In 2005, thePMCC performed four or five ofthese procedures per year; today it

performs three or four every month,according to Rao, who created theBiVAD program 14 years ago.

After a few days, Fung showed signsof recovery. Less than two weeks af-ter being attached, the BiVAD wasremoved and her own heart tookover.

Fung stayed at the PMCC for nearlysix weeks. More than half that timewas spent relearning things mostpeople take for granted.

“I had breathing tubes. I lost abilityto eat — the reflex of swallowing, youlose that after laying down for 14 or 15days,” she explains. “I had to learnhow to talk because there was a (tra-cheotomy) hole in my throat.”

After her recovery, Fung and herhusband earned their MBAs togeth-er at McMaster University and gotmarried after graduation. She defiedthe odds again, when she becamepregnant with her first child fouryears ago.

Because of her history, Fung’s was ahigh-risk pregnancy. That meantmonthly ultrasounds, not only tomonitor the baby, but on her heart aswell. Today, her 3-year-old daughteris happy and healthy and, a little overa year ago, was joined by twin broth-ers.

Her annual followup visits withdoctors at PMCC “are mostly justchit-chat now,” Fung says. Gone arethe stress tests and regular ultra-sounds.

She won’t ever forget what hap-pened to her, but the only visualmarker, a scar from her collarbone tobelow her breast, is fading.

“It doesn’t hurt anymore, either,”she says. It’s an indication the experi-ence is well behind her, part of herhistory.

“Life is normal now.”

> BEATING THE ODDS

After being diagnosed with myocarditis in 2005, Sally Fung, right, spent six weeks at the Peter Munk CardiacCentre. She has since recovered and now has three children, a daughter and twin boys, with husband, Tim.

TIM FRASER FOR THE TORONTO STAR

Mechanical heart helps battle rare disorderPotentially fatal conditioninterferes with heart’s abilityto pump blood to the body

JASMINE MILLERSPECIAL TO THE STAR

“When she arrived, I was worriedshe wouldn’t make it to theoperating room in time.” DR. VIVEK RAOCHIEF OF CARDIAC SURGERY ANDDIRECTOR OF TRANSPLANT ANDMECHANICAL SUPPORT AT PETER MUNK CARDIAC CENTRE



The past and future are members ofthe same team at Peter Munk Cardi-ac Centre, and their names are doc-tors Tirone David and Mitesh Badi-wala.

They are of different generationsand medical upbringings — David,70, is a veteran in the field, whileBadiwala, 36, is one of the hospital’snewest recruits — but as part of thesame expert team of surgeons, thedecades that separate them in agecould bolster the future of cardiacsurgery in the city and around theworld.

From pigs in Toronto labs to beat-ing human hearts on Chicago oper-ating tables, Badiwala, has circledback home again to the team thatgave him his start. After a year as atravelling fellow at NorthwesternUniversity and a “taste of the Amer-ican health-care system,” it was timeto come home.

“They tried to keep me at North-western, but I was too proud a Cana-dian to stay,” Badiwala says. “It’s avery collegial group here.”

He wasn’t always so sure-footed,though. When he started medicalschool in 2000 at the University ofToronto, he had no idea where hewanted to go in the field. But soon,one of his earliest mentors, Dr.Heather Ross, introduced him to car-diology. The first summer he had offduring med school, he worked in alab and watched some of his now-partners in the operating room andthat was that.

“I got hooked. It was almost like adrug,” he recalls. “I was totally ad-dicted to cardiac surgery. I loved theintensity of it, the technical detailthat was required. The fact that pa-tients can get really sick in a mo-ment’s notice and you’re there to al-most rescue them at times.”

During work on his PhD, he assistedon more than 100 organ retrievalsand transplants. He says that time

was a kind of “informal fellowship”in the practice of heart transplants, aprocedure near the end of spectrumof cardiac surgery. For a young stu-dent who hadn’t completed the restof his cardiac surgical training, thiswas uncommon.

“Ironically, the first cardiac surgeryoperation that I learned and wascomfortable doing was heart trans-plantation — not coronary bypass,not valve repair — not all the othercommon stuff,” he says. “Not all car-diac surgeons do transplantation.Usually, you have go away and learnhow to do it, but I kind of learned itup front.”

This cemented his ambitions andtransplantation became his passion.

When a young man in his 20s land-ed on Badiwala’s operating table, heknew even more that this was the

practice for him. “His skin was grey,he was really sick. We couldn’t get aheart for him, because he was toosick to wait,” he recalls. “We put apump into him. And that in and ofitself transformed him.”

At the time, about eight years ago,the young man had to walk aroundwith a backpack controlling the loudpump. Since then the technology has“totally evolved twice over,” says Ba-diwala, but still, it worked. “Seeinghim get better with the pump was aneye-opener for me — a guy who wasalmost dead being kept alive with apump,” he says, recalling the amaze-ment he felt as a trainee at the hospi-tal.

Called a left ventricular assist devic-es, or LVAD, the pump substitutes asthe left side of the heart where theproblem typically is, Badiwala says.

They drain blood from the left side ofthe heart and use the LVAD to pumpit to the rest of the body through theaorta.

Badiwala says the man would havelikely been using a first or secondgeneration pump then. Today, theyare already on to the fourth genera-tion of pumps.

“Like so much in the world of tech-nology, it’s constantly evolving. Likethe size of cellphones and MP3 play-ers over the last several years, theseheart pumps too are shrinking insize,” he says. “They used to be so bigthat we’d have to put them in thebelly. But now the pumps are sosmall that we can just fit them in thesame sack that the heart is normallyin. The operations are becoming lessand less invasive.”

That’s one of the keys to the future

of cardiac surgery: minimally inva-sive operation. But more than thatfor the doctors at Peter Munk, thekey is as simple as teamwork. Multi-disciplinary practice and collabora-tion is one of the primary goals forthe centre’s future as it strives tobecome the “valve centre of excel-lence” globally, says Badiwala. “Wehave all these pockets of expertiseand we’re slowly kind of mergingthem within our institution.”

Instrumental to that team is TironeDavid, the “legend,” as more thanone fellow doctor at Peter Munk callshim.

“Everyone knows him,” says Badi-wala. “To this day, he operates veryfrequently. He does a better job thanmost of us do on a bad day for him,”he laughs. “For me to have a mentorlike that to help me as I start mypractice is an incredible experience.”

In some ways, Badiwala is taskedwith filling David’s shoes.

“Dr. David is a legend, he really is,”says Heather Ross, one of Badiwala’sfirst mentors. “Those are rather gi-normous shoes to fill. Mitesh prob-ably doesn’t look at trying to fill thoseshoes as to make his own footprint. Ithink that is a brilliant way of think-ing about it.”

Indeed, David’s curriculum vitae isextraordinary. Perhaps his crowningachievement is having an operationnamed after him: the “David Proce-dure.” In the ’80s, David operated onyoung patients with a genetic abnor-mality that caused their aorta to ex-pand. These patients were dying bythe age of 40, he says. But in 1989 hedeveloped a procedure in which theaortic root is replaced without re-placing the aortic valve. Now, peoplewith the abnormality live normallives.

Despite his age, David has no plansto retire. “I’m 70 years old, howevermy clinical performance is no differ-ent than when I was 40,” he says,decrying human perception of time.

“My degree of productivity hasn’tstopped yet. But eventually I’m sure.Like any aged professional, we al-ways slow down. I don’t know whenit’s going to be. I think I am in thetwilight years of my productive life.”

> SURGERY

Heartfelt commitment spans a generationTirone David, 70, shares a similar life-saving passionwith Mitesh Badiwala, 36

JONATHAN FORANI SPECIAL TO THE STAR

Dr. Tirone David, left, is considered a “legend” by his peers; Dr. Mitesh Badiwala could be the one filling his shoes.STEVE RUSSELL/TORONTO STAR



They come from all over the world. “We have fellows from Australia, the

U.K., Israel, Argentina, Chile, Saudi Ara-bia and all over Canada,” says MichaelMcDonald, a staff physician with the Pe-ter Munk Cardiac Centre. “You see a widespectrum of illness and patient popula-tions you wouldn’t see at many of themedium-sized Canadian centres or evenin the many United States training pro-grams,” he says.

What’s more, PMCC offers fellowshipsin 10 different disciplines. The aim is todevelop skills that can be passed on totrainees in the fellows’ countries of ori-gin, improving care around the world.Here’s what several of its past fellowsgained.

Finn Gustafsson, medical director of cardiac transplantation Rigshospitalet, Copenhagen, DenmarkGustafsson credits the sheer volume ofoften-complex heart disease cases he sawin Toronto, as well as the expertise hepicked up from its doctors, with roundingout his training and enabling him to catchdifficult-to-diagnose cases.

In addition, he says, “I learned a lotabout how to manage patients, especiallywith the immune-suppression of hearttransplant patients.” He “copied exactly”from PMCC the role of heart transplantco-ordinators — highly trained nurseswho follow patients through the entireevaluation procedure and through pre-operative and post-operative care.

Introducing co-ordinators and other or-ganizational techniques has helped theheart transplant program at Rigshospita-let run more smoothly and efficiently, hesays.

Douglas Greig, co-ordinator of clinical cardiology and staff doctor, heart failure program Pontifical Catholic University of ChileAfter completing a fellowship at PMCCin 2011, Greig is starting a pilot project inChile he says is strongly influenced bywhat he saw in Canada.

“Canada has a good model because youhave a lot of nonspecialized doctors whoassess patients and transfer them to spe-cialized centres (such as PMCC) for acute

care. They are treated and then trans-ferred back to their family doctors.” Ifevery cardiac patient received specializedcare the numbers would be overwhelm-ing, he says, “but Canada is very efficientat managing patients.”

Greig’s project will use a similar ap-proach — training doctors in three clinicsserving poorer areas to follow guidelineson performing checkups to detect ad-vanced cardiac failure patients. Those pa-tients can then be referred on to special-ists.

Dominic Parry, cardiac surgeon Hamilton General Hospital, HamiltonParry couldn’t sleep. It was the night be-fore a major surgery on a patient in his40s.

“He had a bad case of endocarditis — aninfection of the heart valve,” Parry recalls.“I spent the night before going throughmy notes from my fellowship at the PeterMunk Cardiac Centre. I kept a thoroughdiary including pictures of all the tech-niques and tips.” The patient is now doingwell.

Part of the credit for the life-saving op-eration goes to the “incredible team” inHamilton, says Parry. But he also attri-butes the experience and teaching he re-ceived during a two-year fellowship withPMCC. Parry chose PMCC in part for its“well-deserved worldwide reputation forexcellence.”

Luke Burchill, assistant professor,medicine and cardiologistKnight Cardiovascular Institute, Oregon Health & Science University,Portland, Ore.Burchill serves a group of patients whohave often been overlooked — adultsborn with a heart abnormality.

While a fellow at PMCC from 2009-12,Burchill studied adult congenital heartdisease and heart failure. The draw: Thecentre’s congenital cardiac care programis one of the oldest and largest in theworld.

“They’re really world leaders in provid-ing such care,” he says.

With the help of Heather Ross, directorof PMCC’s heart transplant program,Burchill has been studying how to betterunderstand and evaluate risk prior totransplant in adult congenital heart dis-ease patients whose hearts are failing.

> FELLOWSHIP

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More healthcare stories with happier endings.



It took heart attack-like symptomsfor Tony Mursic to end his heart carehiatus.

Mursic, 50, was born with a ventric-ular septal defect — a hole in theheart. He is one of the 200,000 Cana-dian adults living with congenitalheart disease. Those with the chron-ic condition, which affects 1 per centof the general population, sufferfrom defects that include holes andabnormal valves and connections inthe heart.

“I think what they used to call usback then were ‘blue babies.’ Becausethere was a lack of oxygen, we hadkind of a blue tinge to our skin,” saidMursic, who was treated at the Hos-pital for Sick Children throughoutchildhood and later at the PeterMunk Cardiac Centre at TorontoGeneral Hospital.

People with congenital heart dis-ease are at risk of arrhythmia, heartfailure, endocarditis and death.

Mursic stayed in hospital formonths after he was born. Today, hewould likely receive surgery to repairthe hole, but back then the proce-

dure was considered too risky. As hegrew older, he experienced heart pal-pitations, troubled breathing andwas unable to participate in manysports or gym class activities.

“It’s always kind of a tough thing asa kid to sit and watch the other kids,”he said.

He had regular appointments atSick Kids until age 17, when he feltmore stable and stopped wanting togo as often. Then, while playing agame of softball in his early 20s, hebecame dizzy and couldn’t breathe.That’s when he checked into the To-ronto Congenital Cardiac Centre forAdults (TCCCA) at the Peter MunkCardiac Centre.

One of the largest and oldest pro-grams of its kind in the world, theTCCCA takes on about 200 patientsreferred by Sick Kids per year.

“Our mission is to provide compre-hensive patient centre care,” said di-rector Erwin Oechslin.

That includes regular testing andaccess to specialists in pregnancy,hypertension, high blood pressureand problems that relate to otherorgans, such as the kidney and liver.

The program is growing, up from

9,000 patients in 2006 to its current17,000, said Oechslin. That’s partiallybecause advances in medicine areboosting life expectancies.

“Sixty years ago, only 20 per cent ofbabies born with congenital heartdisease survived,” said Oechslin. To-day, that number is 90-95 per cent.

The increase also means there aremore complications that doctorsaren’t familiar with treating. Treat-ment options range from simplymonitoring a patient to surgery,drugs and transplants, said Oechslin.

A common misconception, he said,is believing a surgical intervention isequivalent to a cure.

“Even though the heart was re-paired during childhood, it can have

long-term issues.” He said about 70per cent of congenital heart diseasesufferers do not follow up with ex-perts — a major problem.

In addition to medical interven-tions, the TCCCA offers psychologi-cal care.

Adrienne Kovacs, a psychologistwith the program, said about one-third of patients experience clinicaldepression or anxiety. This comesfrom the added stress of dealing withlifelong medical challenges.

“The goal is also to provide themwith coping skills to help them feelready and more able to manage liv-ing with a congenital heart defect,”she said.

To make the transition from Sick

Kids to adult care easier, the centrerecently launched Iheartchange.org,a hub of resources for people livingwith congenital heart disease, in-cluding medical information, copingtips and ways to connect with otherpatients.

Mursic, who is currently on medi-cation for hypertension and bloodpressure, said he’s happy with thecare he’s received. He goes for check-ups every six months and tries tokeep active through walking, hikingand fly fishing.

“Doctors are learning more.They’re seeing patients live longerwith this sort of thing,” he said.

“The advances in everything cer-tainly give me a better quality of life.”

> CONGENITAL DISEASES

Hoping to treathearts and mindsThe Toronto Congenital Cardiac Centre, one of the largest inthe world, offers medical interventions and psychological care

MANISHA KRISHNAN STAFF REPORTER

Tony Mursic, who was born with a hole in his heart — a so-called ‘blue baby’ — says he’s happy with the care he’sreceived from the TCCCA.

SASHA MORIC, Q MEDIA

Before any new medication or deviceis prescribed by a doctor, it under-goes a rigorous series of tests.

Created in 2011, the Peter MunkCentre of Excellence in Multination-al Clinical Trials is at the forefront ofclinical trials involving cardiac, car-diovascular and vascular diseaseconducted worldwide. What else?

The PMCC Centre of Excellence inMultinational Clinical Trials is:á One of seven centres of excellenceat the PMCC created to transformhow heart disease is treated globally.á Leading more than 20 interna-tional clinical trials around theworld, involving 30,000 patients and400 physicians, scientists and re-

searchers, in 20 countries.á Involved in 70 clinical trials in:heart failure, vascular surgery, adultcongenital heart disease, echocar-diography, electrophysiology, cardi-ac imaging and interventional cardi-ology.á Led by Michael Farkouh, PMCCcardiologist and international expert

in cardiovascular prevention andhow it relates to other medical condi-tions including diabetes.

The PMCC Clinical Trials Unit is:á Working closely with the MayoClinic on a trial of genomics in themanagement of patients with coro-nary disease. Its partnership uses the

strengths of both institutes and is anexample of individualized medicine.á Partnering with the Banting andBest Diabetes Centre to address themost important questions of diabe-tes and heart disease.

A novel trial of non-invasive lasertherapy to reduce abdominal obesityis being conducted.

> A PORTFOLIO OF EXCELLENCE

The timeline of any new drug begins with a clinical trial

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The entire heart captured in 0.275 seconds

CONGRATULATESTHE PETER MUNK CARDIAC CENTRE:A WORLD CLASS FACILITY COMMITTED TO THEVERY HIGHEST STANDARD OF PATIENT CARE



Alvin Dickstein’s heart has been on arough ride.

A heart attack, cardiac arrest andthree operations to calm the “electri-cal storm” of irregular heartbeatshave taken their toll. Dickstein nowsuffers from chronic heart failure.

“I used to be a Type A personality,”he says, “but over the years I’veslipped a few letters down the al-phabet.”

Today, Dickstein, 75, is building uphis heart health with constantfollowup by his cardiology team in anew way: Instead of having to makeregular trips down to the hospitalclinic, he takes his blood pressureand weighs himself every morningfrom home, then sends his readingselectronically to Heather Ross, di-rector of the Ted Rogers Centre ofExcellence in Heart Function at thePeter Munk Cardiac Centre.

Ross responds within 15 minutes tolet him know if he’s on track orwhether he needs to adjust his medi-cation, set up an appointment at theclinic or make a quick trip to emer-gency. Most of the time, he gets thethumbs-up from Ross.

Chronic heart failure patients atPMCC such as Dickstein are increas-ingly communicating with theirhealth-care practitioners about theirvital signs, symptoms, mood chang-es, dietary and exercise habits usingdigital technology — from mobilephone devices to web-based e-coun-selling programs.

“We know that one in four Canadi-ans is diagnosed with heart failureafter the age of 40,” says Ross, “whichcreates an enormous burden on thehealth-care system. We need to findbetter ways to treat and care for all ofthese patients in order to reduce ourcurrent high rates of hospital read-mission. Telemonitoring is one verycost-effective method to help us to-ward that goal.”

The Peter Munk Cardiac Centre ison the leading edge of an emergingtechnology that promotes self-care.The remote monitoring systemshave received a catalyst grant fromthe Canadian Institutes for HealthResearch and funding from the cen-tre’s innovation committee.

One device is the FitBit, whichmonitors physical activity. Threeyears ago, Gordon Chong, 71, a re-tired dental surgeon, suddenly be-came short of breath after walkingshort distances, a major symptom ofheart failure.

Now, he uses the lightweight, rub-ber FitBit wristband that relays thesteps he takes and distance travelledto his PMCC cardiac team.

Joseph Cafazzo, a biomedical engi-neer and lead for the Centre forGlobal eHealth Innovation, says a

Mayo Clinic study showed FitBit da-ta was a predictor of how well a pa-tient would thrive.

“FitBit is just one device amongmany that may help patients in thefuture” Cafazzo explains, “withprompts to take medication and bymanaging several chronic conditionsat once.”

Vital sign measurements are cru-cial to monitor, but lifestyle factorsare also important. PMCC’s web-based e-counselling program hasproved successful in helping heartfailure patients live from day to dayin the best health possible.

Robert Nolan, director of the cardi-ac e-health and behavioural cardiol-ogy research unit, and his team havedeveloped an e-counselling programthat comes as close as possible tohaving face-to-face sessions.

The program offers support andguidance for patients who mustmake critical lifestyle changes to im-prove their quality of life, says Nolan.Available to them are expert videos,self-help tips, and dramatic vignettesdiscussing real-life challenges. Pa-tients can also chart their diets,weight and blood pressure, assesstheir progress and see real results.

Nolan and his team have launched aclinical trial with the hope of recruit-ing more than 275 heart failure pa-tients in Vancouver, Toronto andMontreal to test the effectiveness ofthe e-counselling program. Onestudy participant, Geoff Elliot, 69,was depressed when he left the hos-pital knowing he had to make someserious adjustments to his lifestyle.

But since he began using the e-counselling program in June, Elliotcredits it with motivating him tomake major changes such as walkingfour kilometres three times a week,and eating more vegetables and fruitinstead of his former diet of dough-nuts, french fries and pepperoni piz-za. He likes the “help” button featureto chat live with experts who cananswer his medical questions.

“I really feel as if I’m attached to mymedical team even though I’m nolonger in the hospital,” says Elliot. “Idon’t feel so alone.”

Dickstein, too, feels he has madeenormous progress through tele-monitoring and keeping to a regularphysical activity program of riding astationary bike and lifting weights.

“I’ve climbed back up the alphabetof health,” says Dickstein. “I’m now aType A- personality.”

> TELEMONITORING

Telemonitoring allows cardiac patients, such as Alvin Dickstein, to taketheir blood pressure and send their readings electronically to their doctors.

THOMAS BOLLMAN FOR THE TORONTO STAR

E-counselling helpskeep patients on trackPeople can now sendinformation about theirhealth from comfort of home

JUNE ROGERSSPECIAL TO THE STAR

Dr. Joe Cafazzo, a biomedicalengineer, demonstrates thetelemonitoring cellphone app.

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TedRogersResearch.caFor more information visit

Partners in the Ted Rogers Centre for Heart Research

On behalf of every Canadian,A HEARTFELT THANK YOUto the Rogers family.

On November 20, 2014,The Hospital for Sick Children,University Health Network andthe University of Toronto officiallylaunched an unprecedented initiative.This unique partnership bringstogether a network of globallyrecognized clinicians, scientistsand engineers to solve one of today’smost challenging health conditions– heart failure.

Our goal? To reduce heart failuresubstantially within the next decade.It is an ambitious vision shared bythe Rogers family.

Through an unparalleled gift of$130 million – the largest evermade to healthcare in Canada –the Rogers family has made atransformative investment to create the

A fitting legacy to one of Canada’sgreat pioneering entrepreneurs,the Centre will bring together the verybest minds to transform the future ofheart health for children and adults.

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