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miles nadalAbove: Miles Nadal

Written by: Heidi Singer
Photos by: John Packman

Kyla Bretney’s heart problems began shortly after a routine hysterectomy. She woke up one morning, took a few steps, and her heart started racing. Soon she began to feel breathless. She was diagnosed with a small pulmonary embolism and put on blood thinners, but those only made her surgical wounds bleed profusely.

What followed was a three-year nightmare of false starts and dead-ends in a quest to help the Whitby mom, just 34 at the time. Nothing worked and she kept getting worse. Taking a few steps would send her heart racing past 125 beats per minute. She had to give up her dream job and could barely care for her three children. “Even if I was sitting, all it took was to start talking to someone and my heart was racing,” Kyla recalls.

Physicians at four hospitals in three cities were out of medications, surgeries and tests when someone thought of Dr. Susanna Mak. “My cardiologist said there was this fantastic doctor at Mount Sinai Hospital who was doing research that he thought could be helpful — maybe pick up something that everyone else had missed,” Kyla says.

Her doctor was right.

Monika WoodruffAbove: It takes the combined effort and expertize of multiple health-care professionals to keep the Miles Nadal Heart Centre ticking. Left to right: Dianne Locke, Manager, Ambulatory Cardiology; Sheron Green, Echo Receptionist; Victoria Harvey, Cardiology Technician; Rashmi Varshney, Echo Technical Director, Hermione St. Clair, ECG Technician; Teresa Ruggeri, ECG Office Coordinator

Dr. Mak is a pioneer in testing that measures how much blood the heart can pump during exercise. Through intimate observation of the mechanics of the heart, she finds precise explanations and treatments for breathlessness and heart failure — especially in women, whose hearts are constructed in subtly different ways than men’s. Through sensors inserted into the heart chambers, Dr. Mak detects the system malfunctions that cause breathlessness in patients with heart disease. The process requires specialized equipment and analytical software to conduct studies that involve comprehensive measurements and imaging of heart function.

Now, she will be able to expand her work, thanks to the establishment of the Miles Nadal Heart Centre and an $11 million gift from philanthropist and business leader Miles Nadal. The gift will allow Dr. Mak to map what goes wrong when heart disease causes breathlessness, leading to better treatments and, hopefully, earlier detection of heart failure.

“I’ve always prided myself on being an entrepreneur and I see Sinai in that vein: they’re challenging conventional wisdom, doing things in an entrepreneurial way,” says Mr. Nadal. “I believe what we’re going to do at the Miles Nadal Heart Centre will be world leading and will change the health system approach to cardiac care.”

Solving the mystery of Kyla’s heart disease

In an era when researchers are often focused on the genetics of disease, Dr. Mak looks for mechanical clues to the cause of breathlessness and heart failure that may have been overlooked. And Kyla, it turned out, had a diagnosis everyone had missed.

Dr. Mak’s test requires catheterization, a normally invasive procedure in which sensors are snaked into the chambers of the heart through a tube. In the past, it has been hard to find healthy volunteers to study, but Dr. Mak — who is the Director of the Mecklinger Posluns Cardiac Catheterization Research Laboratory — and her team of highly-trained nurses make the procedure as painless and easy as possible. While the catheter is typically introduced into the body through the leg or neck, Dr. Mak’s team accesses the heart through an artery in the upper arm, making it less invasive and easier to recruit test subjects with healthy hearts. This crucial step shows how hearts should normally pump blood during mild exercise, so Dr. Mak can pinpoint what’s different in sick people.

Kyla’s racing heart was the most glaring issue, but nobody knew whether it was the cause of her problems or the result of some other cardiac defect. And she couldn’t tolerate the beta blockers that would have slowed her heart rate and helped answer the question.

Above: Kyla Bretney

Dr. Mak showed that Kyla’s fast heart rate was indeed the cause of her troubles. The rapid beats were preventing her heart cavity from properly filling with blood. This was forcing her heart to work overtime, using a lot of energy to achieve very little; a condition called inappropriate sinus tachycardia.

Through her precise observations, Dr. Mak discovered the reason Kyla’s heart was beating too fast — a defect in her ‘pacemaker’ function — and found a very specific drug that would work on the single channel that regulates the heart’s pacemaker cells.

For Kyla, the changes were immediate and profound.

“The first week I started taking it, I was seeing my heart rate sit around the 80s and then I remember one day looking at my Fitbit and seeing 78,” she recalls. “That was the first time in years I’d seen a normal heart rate. I screen-shot the Fitbit and sent it to my husband. He was like, ‘no way, that’s impossible!’ I’m like, ‘nope, this is my heart rate right now!’”

Today, Kyla is able to make dinner for her children several times a week and she can attend some of their activities again. She has good and bad days, but now that the under-lying mechanical problem is under control, she’s working to strengthen her heart, weakened by years of inactivity.

“I’m optimistic,” she says. “We’re just starting the therapy, but we’re seeing signs that it’s successful, although it’s still unpredictable.” For now, Kyla says her ambitions are realistic: “I’d love to do more with my kids, and hopefully even have a part-time career.”

Safe pregnancies for women with heart disease

Kyla’s heart problems began after a partial hysterectomy, suggesting that sudden shifts in hormones could have played a role. That would not be surprising to Dr. Candice Silversides, a cardiologist who conducts world-leading research into heart problems and pregnancy through her work at Mount Sinai Hospital as Head of Obstetric Medicine, and in the Medical Disorders of Pregnancy program, and the Pregnancy and Heart Disease program — which is part of the Miles Nadal Heart Centre.

Hormone changes such as those during pregnancy can contribute to heart troubles, says Dr. Silversides. “Pregnancy puts extra stress on the heart, and for some women with heart problems, this can result in cardiac complications during pregnancy, labour or during those first few sleep-deprived months with a new baby,” she says. “Our job, as doctors, is to help women understand these risks, change medications that might be unsafe for the baby, and monitor the pregnancy closely for those who chose to become pregnant.

Sinai physicians were the first to develop a risk score to predict those women with the highest chance of complications during pregnancy. Dr. Silversides and her colleagues recently created an even more accurate risk score that can be used by doctors around the world to predict pregnancy complications, based on a study of 2,000 women.

Left to right: Kelly Grier with husband Miles Nadal; and Sinai Health System CEO, Dr. Gary Newton at the entrance to the recently named Miles Nadal Heart Centre.

“I think we’ve been able to better understand and treat high-risk pregnant women,” says Dr. Silversides, whose pregnancy and heart disease program will also receive a boost from Mr. Nadal’s gift. “Some of the biggest risks occur in women with heart valve disease, weakened heart muscle or pulmonary hypertension. Our goal is to identify the women who might develop complications — and try to prevent those complications in both mother and baby.”

Not many years ago, before physicians had a good understanding of pregnancy risks, Sara Jankowski would have been told she should never consider having children. The Woodstock resident was born with a serious heart defect requiring major cardiac surgery during her childhood.

The right precautions

But Sara loves children and wants at least two. Luckily, thanks to Sinai Health research, the medical community now has a better understanding of pregnancy risks and many women like Sara are reassured that pregnancy can be managed safely. Dr. Silversides, her cardiologist, always told Sara she could get through pregnancy safely with extra monitoring and some precautions during delivery. So last year, when she learned she was pregnant, Dr. Silversides was the second person Sara and her husband told.

At first, everything went well. But during her third trimester, the weight gain and increased blood flow started to put stress on Sara’s heart.

“There were a lot of arrhythmias and chest pains,” recalls Sara. “Before I got pregnant, it was once in a blue moon. This time, the frequency made me nervous. Going up the stairs would be bad — I’d get winded. I would try and go up fast enough that my heart wouldn’t realize what I was doing until I was at the top.”

Dr. Silversides put Sara on a new medication to slow down her racing heart and Sara, who works at another hospital as a cardiac sonographer, monitored herself using a Fitbit. Toward the end of her pregnancy, she and Dr. Silversides decided it was time for her to stop working.

Above: Sara Jankowski and baby Kasper

Delivery was “absolutely awesome,” says Sara. The Mount Sinai Hospital pregnancy and heart disease team consists of specialized cardiologists, obstetricians, anesthetists and nurses. Thanks to a highly coordinated team, approximately 250 babies a year are safely delivered in high-risk women with heart disease.

“I was so excited to push because normally Candice doesn’t want me to lift heavy weights,” laughs Sara. “This was like squatting 300 pounds — it was my moment!” Her son was born after three contractions.

Sinai Health’s Pregnancy and Heart Disease program works closely with the Toronto Congenital Cardiac Centre at Toronto General Hospital (TGH), a nearby cardiac program. The Toronto Congenital Cardiac Centre for Adults — where Dr. Silversides is Director of Research — looks after young women, such as Sara, who are born with heart disease. Many of these women come to Sinai to receive advice before pregnancy and to delivery their babies. These complementary cardiac programs show how patient care improves when hospitals work together.

“We contribute in a very Sinai way,” says Dr. Mak, whose testing helps to identify transplant candidates for TGH. “We do something smaller yet extremely specialized and fairly rare. It’s a can-do culture.”

The other 99 per cent

Sinai Health cardiologists are also known for the most general of skills — taking care of the 99 per cent of patients with heart failure who will never receive a heart transplant.

“For the overwhelming majority of people, heart disease is a chronic issue where we need to help them find ways to manage and live well with it,” says Dr. Alan Barolet, Site Director for Cardiology at Mount Sinai Hospital. “I think we do a very good job of helping people, particularly once they get back home, to have as high a quality of life as possible.”

A major advantage is that all of the hospital-based cardiologists at Sinai also run outpatient clinics, allowing them to follow patients for many years and to coordinate care between daily life and any hospitalizations they may need.

Caring for the whole patient

“One thing we do very well is that we take ownership of the patient.” That continuity of care, says Dr. Barolet, “is a better way to treat patients, and I think it translates to better outcomes.”

Above: Cardiologist, Dr. Susanna Mak, is the Director of the Mecklinger Posluns Cardiac Catheterization Research Laboratory at Mount Sinai Hospital. The Centre uses state-of-the-art imaging to look at the mechanics of the heart and is at the international forefront of understanding heart disease.

Dr. Barolet recently treated a patient who had been flagged by orthopedic surgeons because her vital signs were off during surgery. It turned out she had some serious signs of heart disease that she was unaware of.

“Now, the lady with the broken elbow is delighted that we are finally going to work out why she keeps fainting all her life,” he says. “Providing that sort of care, taking care of the whole patient, is gratifying, and it’s a big part of what we do.”

It’s also a big part of the future of medicine. It’s what Miles Nadal envisions for the future of heart care in Canada, and why he chose to support this important work.

“Because of the hospital’s end-to-end capability of serving the patient, and the extraordinary dedication of the physicians and researchers I’ve met, I thought this was the perfect opportunity for my family to make this commitment of time, talent and treasure to this wonderful institution,” he says. “I think the Miles Nadal Heart Centre is going to be the future of cardiac care in Canada.”

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