2013 AMREP Research Report

1. Department Details

Name of Department Cardiovascular Medicine
Name of Department Head Professor Anthony M Dart
Title of Department Head Director
Dregrees of Department Head BA DPhil BM BCh FRCP FRACP

 

2. Brief description of Department and main areas of research

The department of Cardiovascular Medicine investigates and treats all aspects of adult cardiac disease. It is located on the 3rd floor of The Alfred with adjacent areas for inpatient care and ambulatory services. It has two full and one right heart cardiac catheterization laboratories providing 24 hour, seven days a week care for acute cardiac patients. Noninvasive investigations include echocardiography (including transoesophageal, 3D and stress) and in conjunction with the department of Radiology, cardiac MRI and cardiac CT. In conjunction with the department of Cardiothoracic Surgery and Alfred Intensive Care Unit, it offers statewide services in mechanical circulatory support and cardiac transplantation. In addition to the research carried out in the clinical investigation areas, the department has a number of procedural rooms reserved for research use in which a number of procedures are undertaken (including microneurography, plethysmography, adipose and muscle biopsy, etc). Many staff members have honorary or conjoint appointments with Monash University and/or BakerIDI Heart & Diabetes Institute.

Research is undertaken and promoted throughout the department. Funding for research is provided through NHMRC program, project and development grants and centre for research excellence awards, NHMRC people support as well as funding from the National Heart Foundation and commercial sources In the cardiac catheterization laboratory research has focused on novel noncoronary interventional procedures. Imaging research has been particularly focused on cardiac magnetic resonance imaging. Cardiac electrophysiological research has been undertaken in relation to various aspects of atrial fibrillation whilst cardiovascular physiology study have addressed the important problem of heart failure with preserved ejection fraction. The department contributes extensively to clinical trials in cardiovascular disease and continues to provide opportunities for research training for both clinical and nonclinical staff. The department is an active participating contributor to interventional cardiology and device registries.

 

3. RESEARCH HIGHLIGHTS AND ACHIEVEMENTS

A) A brief description of major findings or outcomes from research projects conducted during 2013.

Cardiac Catheterization Laboratory: Research in the cardiac catheterization laboratory has continued into a number of novel noncoronary interventions and devices. Of particular note, Prof David Kaye and Prof Stephen Duffy have recently published the first paper describing a new medical device for reducing the radiographic contrast load experienced by patients during coronary angiography and other procedures. In certain patient groups this can have important and deleterious consequences. The device was developed by Osprey Medical, the company cofounded by Prof Kaye and the promising early results have led to a large scale multicentre interventional trial which is now underway.

A/Prof Walton continues to lead research into a variety of noncoronary devices and interventions and the department has now undertaken more than 100 cases of percutaneous aortic valve replacement (TAVI). In addition to TAVI, Dr Walton and his team have investigated patent foramen ovale closure and atrial appendage isolation for stroke prevention, inter atrial shunt creation for the treatment of heart failure and percutaneous renal denervation for blood pressure control and improvement of renal and cardiac function. In addition to contributing to international research efforts in this field, this provides the opportunity for additional investigator led research. The department is also a major contributor to registry data and is represented by Dr Duffy on the VCOR steering committee which will extend the pioneering work conducted in the Melbourne Interventional Group by Dr Duffy and his colleagues.

Noninvasive Cardiac Imaging: Research continues in all aspects of cardiac imaging with particular focus on cardiac MRI. The ability of cardiac MRI to identify both regional and diffused fibrosis has been further confirmed in studies by A/Prof Andrew Taylor and his colleagues. Notable research published during the year as part of his PhD by Dr Ellims identified the role of diffused cardiac fibrosis in determining ventricular stiffness in diastolic functions. In addition to contributing to mechanistic understanding this finding may have particular relevance in evaluating the use of antifibrotic agents in which an accurate and noninvasive method of identification will be a valuable attribute. The ability of cardiac MRI identified fibrosis to predict propensity for serious arrhythmia development has been shown and has potential for clinical utility in stratifying patients likely to benefit or not, from deployment of implantable defibrillators. Cardiac MRI has also been valuable in inter-disciplinary studies in particular with electrophysiological laboratory as detailed elsewhere. Dr James Hare is using non invasive cardiac imaging to identify patients likely to be at risk of developing cardiac complications as a result of therapy to treat cancer.

Electrophysiology: A/Prof Peter Kistler continues to lead an active and productive research program in clinical electrophysiology. A particular highlight of this year was the award to PhD candidate Alex McLellan for the Young Investigator Award for this finding that cardiac fibrosis as identified by MRI was a successfully predictor of the success of atrial fibrillation ablation. Other studies resulting from collaboration include evidence that restoration of sinus rhythm improves cardiac function in patients with cardiomyopathy. In another notable achievement the electrophysiology department was the instigator and a major contributor to randomized trial investigating relative benefits of minimal or maximum ablation strategies (the MIMIMAX trial) in controlling paroxysmal atrial fibrillation.

Cardiovascular Physiology: Studies directed by Prof Kaye have been investigating the physiological basis for the condition known as heart failure with preserved ejection fraction now increasingly recognized as a common form of heart failure leading to hospitalization. In particular novel approaches used in the department have been to study cardiac performance both at rest and in response to exercise to more closely mimic the conditions under which symptoms can be produced. In closely related work the performance of the right ventricle in patients with pulmonary hypertension is also been assessed under stressed condition. Colleagues from BakerIDI continue to undertake a number of clinical studies within the department in relation to the sympathetic nervous system involving measurement of sympathetic nerve activity (microneurography) as well as biochemical measures of noradrenaline kinetics. Studies completed during the year have identified an important role of the sympathetic system in the production of the metabolic consequences of the polycystic ovary syndrome and have explored the role of the sympathetic nervous system in explain some of the metabolic consequences of dietary interventions in overweight subjects.

Biomarkers: The department has a particular interest in evaluating the role of the novel cardiac biomarker, macrophage migration inhibitory factor (MIF). Studies on MIF elevation post AMI led by Prof Dart and involving collaboration with colleagues in Beijing were published during this year and showed what early elevation of MIF in patients with myocardial infarction was an excellent predictor of final infarct size. The work also involved close collaboration with colleagues at BakerIDI and resulted from the doctoral studies of Dr William Chan, currently a Neil Hamilton Fairly Fellow and due to return to The Alfred in 2014. Further studies are underway to confirm the predictive value of MIF elevation and to establish commercialization partners.

A number of other biomarker studies have been completed or undertaken during the year. These include studies by Dr James Shaw of the relation between circulating vitamin D levels and the extent of coronary disease and also the effects of vitamin D supplementation on a range of cardiovascular and biochemical biomarkers. Collaboration with the lipidomics laboratory at the BakerIDI have been investigating the changes in circulated lipid parameters associated with coronary and vascular disease and including in at risk patient groups such as those with rheumatoid arthritis.

B) Important research-related achievements by staff members of the Department (e.g. awards, prizes, major grants)

  • Dr Alex McLellan: Young Investigator Award as well as finalist and best abstract award (poster presentation) at the Asia Pacific Heart Rhythm Society in Hong Kong (3-6 Oct). "Diffuse ventricular fibrosis measured by T1 mapping on cardiac MRI predicts success of atrial fibrillation ablation." Dr McLellan was awarded post graduate research scholarship.
  • Dr Alex McLellan: Finalist and best abstract award (Oral presentation) at the Asia Pacific Heart Rhythm Society conference Hong Kong Oct 2013: "A randomized controlled trial of a minimal or maximal ablation strategy to achieve pulmonary vein isolation for paroxysmal atrial fibrillation: medium term follow-up (the minimax trial)".
  • Dr Leah Iles: submitted her doctoral thesis in 2013 under the supervision of A/Prof Taylor. She was awarded a NHMRC/NHF Early Career Development Fellowship which will commence in 2014.
  • Prof David Kaye: NHMRC development grant – Oral milrinone formulation for advanced heart failure.
  • Prof Stephen Duffy: NHMRC Project grant (1065162); 2014-2016: "HDL elevation and glucose metabolism: A mechanistic proof-of-concept intervention trial in pre-diabetes."
  • Prof Stephen Duffy: NHF grant-in-aid (G 12M 6453); 2013-2014: "The HDL lipidome: Prediction of coronary plaque rupture and monitoring of therapeutic responses."
  • Dr Tony Walton has been awarded an Associate Professorship by Monash University.
  • Dr William Chan: recipient of NHMRC Neil Hamilton Fairly Fellowship.
  • Profs Kaye and Dart are Chief Investigators (with colleagues from BakerIDI) on continuing NHMRC Program Grant and CRE grants.
  • Profs Kaye and Dart are both (continuing) Senior Principal Research Fellows of the NHMRC.
  • Dr Tomos Walters: Won the best abstract award at the Asia Pacific Heart Rhythm Society conference in Hong Kong 3-6th October. Dr Walters was awarded a NHMRC post graduate research scholarship.
  • Dr Sandeep Prabhu was awarded a NHMRC post graduate research scholarship.
  • A/Prof Peter Kistler is currently support by a NHMRC practitioners fellowship (GNT1026217) to enable him to continue his research into clinical electrocardiography particularly in relation to arterial fibrillation.

4.  2013 FEATURED RESEARCH STAFF

 

A Walton 2013Dr Walton leads catheter laboratory research in 'structural' heart disease, including percutaneous valve deployment, atrial septal intervention, atrial appendage isolation and renal denervation.

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