The Baird Institute

Professor Martin Misfeld, Co-Director of Research, Cardiothoracic Department, RPAH
Senior Consultant, University Department for Cardiac Surgery, Heart Centre, Leipzig

It was in Frankfurt, Germany, when Ludwig Rehn performed the first documented heart operation on the 9^th of September 1896. He closed a hole in the heart of Wilhelm Justus, who was injured in a knife attack. Since then, cardiac surgery has undergone tremendous developments.

Modern cardiac surgery includes less invasive procedures. With a minimally invasive approach, heart valves can be repaired or replaced, and coronary artery bypass surgery can be performed. The aortic valve for example can be operated on via a small incision in the upper right chest.  Access to the mitral and tricuspid valve in contrast, is performed by through the space between the ribs on the right side of the chest.  These procedures can also be performed with the support of a robot, which has already been introduced at Royal Prince Alfred Hospital. In selected patients, Coronary Artery Bypass Grafting (CABG) can be done through a small incision on the left side of the chest. This procedure is performed on the beating heart. In almost all CABG procedures, it is possible to operate without the use of the heart-lung-machine on the beating heart. This technique is called off-pump coronary artery bypass surgery (OPCAB). It has the advantage of avoiding any manipulation of the aorta and as a result reducing the risk of perioperative stroke.

All modern techniques result in less trauma during surgery and patients recover much faster from the procedure. It is important to know, that each technique requires adequate training and expertise.

The cooperation between the Department of Cardiothoracic Surgery at Royal Prince Alfred Hospital and the Leipzig Heart Center, Europe`s number one cardiac centre, aims to expand these procedures in a variety of ways:

1. By introducing specific techniques for the benefit of the patients by experienced surgeons,
2. By educating young surgeons in these techniques eg. lectures, wet lab courses, surgical assistance,
3. By evaluating clinical results of these procedures with cooperative research projects and finally
4. By further improving these techniques, developing specific instruments and cooperating national and internationally on different levels.

Today, modern cardiac surgery can offer each patient individualized treatment with optimal surgical results, fast recovery and excellent long-term outcomes. It is important research that has taken place over the years that has got us to where we are today.

Joining me in today’s episode is Professor Paul Bannon. Paul is an adult cardiothoracic surgeon of international standing with clinical appointments at Royal Prince Alfred, Concord, Strathfield Private and Macquarie University Hospitals.

At Royal Prince Alfred Professor Bannon is the Head of Department of Cardiothoracic Surgery, Co-Chair of the Institute for Academic Surgery, Director of the Robotic Training Institute and the current President of the Medical Officers Association. At the University of Sydney, he holds the inaugural Professorial Chair of Cardiothoracic Surgery and the Bosch Chair of Surgery. He is also the current Head of the Discipline of Surgery for the Sydney Medical School and the Academic Director of the newly opened Translational Research Facility or Hybrid Theatre at the Charles Perkins Centre. He is the Chairman of The Baird Institute for Applied Heart and Lung Surgical Research. Professionally he is the immediate Past President of the Australian and New Zealand Society of Cardiothoracic Surgeons (ANZSCTS) and in that role serves on the steering Committee for the ANZSCTS National Cardiac Surgical Database, the National TAVI Accreditation Committee and is the Cardiac Surgical Chair of the Medical Benefits Schedule review program. For the Ministry of Health NSW he has been in the role of Co-Chair of the Cardiac Devices Committee for the Agency of Clinical Innovation.

Professor Bannon graduated from the University of Sydney in 1987, completed a PhD from the same institution in 1998 and was awarded a FRACS (CTh) in 1998. He has a particular passion for translational research in the areas of congenital aortic and mitral valve disease, biomaterials and biocompatibility, limitation of blood product usage in cardiac surgery, the inflammatory response to bypass and the development of academic surgical careers. He has authored or co-authored more than 120 scientific papers, published in peer-reviewed journals. He is co-editor-in-chief of the Annals of Cardiothoracic Surgery, a Medline listed multimedia journal of cardiothoracic surgery. Professor Bannon has a reputation as the ‘surgeons surgeon’ and has particular expertise in surgery of the aortic root and arch, high-risk re-do surgery, total-arterial coronary artery bypass grafting and surgery for hypertrophic cardiomyopathy.

For more information go to Paul’s website at www.paulbannon.com.au or if you would like to contact Paul directly, [email protected]

Listen to the podcast here:

https://www.exaptec.com.au/podcast/2021/2/4/0drr1p4av9uc5u3x814y3x69vgb5w4

“Good morning Rebecca, this is the Australian Federal Police, can you please confirm your location?”

It was 5.45am, on Thursday 4^th February, 2021 and I can officially say, that this was possibly the worst wakeup call I had ever received.  I was in Perth having begun my 2 weeks of self-isolation in order to make the cut-off to still swim the 20km Perth to Rottnest Island.

The event is the equivalent of swimming from the Sydney Harbour Bridge to Manly return, just over 60% of the English Channel (35km), while the running translation is 80km.

There are only 400 people who complete the swim as a soloist like myself, and 2000 relayers. There is a 60-80% success rate on the day itself due to many variables many of which are outside of your control:

• Your team: You have to find a boat and kayaker to accompany you for both safety and feeding. There are always a handful of boats that breakdown on the day, as well as kayakers who forfeit due to exhaustion or seasickness – it really is luck of the draw.
• Hypothermia: If you spend long enough in warm water, you still get cold. There is a hypothermia medical tent at the end to give a glimpse into how many people do suffer from it. The only strategy to manage this, is to put on as much body fat as you can, to starve off the cold. The other is to wear a full body suit (wetsuits are not permitted).
• Nutrition: We generally eat every 30 minutes and the food is highly sugar based as your body needs to burn carbs for these types of endurance events – which is a shock to me as a paleo person of 5 years. My swim diet includes strawberry yoghurt, coke and lollies.
• Swimmer-induced oedema: This is when the lungs fill with fluid and need draining.
• Tongue swell: When the tongue swells and blocks the throat due to exposure from salt water.
• Timing cut-off: There are markers at the 10k, 15km, 18km marks in the swim, each with times allocated to them – ie if you don’t meet the 15km mark by 2pm, you get disqualified from the swim. Although the timings seem lenient on paper, the weather conditions really determine your timing and performance on the day.
• Currents: Swimming against a current, feels like pushing against a brick wall (literally), and when you stop to feed, you can get pushed hundreds of metres backwards in seconds. This is why it can take hours to move just 1km instead of the standard 20 minutes.
• The Fremantle Doctor: No, he’s not actually a doctor, but he’s a famous wind. This wind is generally 25 knots (a light breeze is about 5 knots) and as the wind intensifies the waves get bigger, you then need to swim under water and wait to be pulled to the top of the wave to get a chance to breath (without the risk of inhaling too much water).

Suffice to say, there are a lot of factors to consider and risks to train for. Most people who undertake this swim, have about 15+ years’ swimming experience underneath their belt and generally weigh about 110kgs.

In my case, I had less than 2 years’ experience, with only 2km as my longest swim, recent aortic valve sparing surgery (courtesy of Professor Bannon) and I weighed 55kgs. I’m sure we can all agree, I had a lot of catching up to do. So instead of undertaking a 3-month training program to prepare for the 20km swim, I had to triple it, with a 9-month training regimen.

I began simulating what solo swimming feels like – just me, swimming alongside a kayaker (or a boat) – from June last year, and we’ve had several experiences on this steep learning curve, dealing with 48 knot winds, sharks, 30 bluebottle stings to name just a few.

I’m very pleased to share, that I completed the Rottnest swim after 9 hours and 42 minutes of swimming on the 20^th February this year.

A big congratulations to one of our Scholarship recipients, Dr Kei Woldendorp, who has submitted the thesis for his MPhil and is currently awaiting allocation of examiners and marking. Below is an interview with Kei about his research, so you will be able to discover more about the work he did during his MPhil.

Cardiothoracic surgical registrar at RPAH, a Master of Philosophy candidate at University of Sydney and the recipient of a Baird Institute Scholarship

What is your research topic?

Neurological injury after transcatheter aortic valve Implantation (TAVI). My research looks at aortic valve intervention post-operative stroke and neurological outcome. I am looking at both open surgical and minimally invasive techniques in my research.

What is the aim of your research?

To investigate the incidence, causes, and potential treatments of stroke and other neurological injury after transcatheter aortic valve replacement. The goal of this research is first and foremost to improve guidelines for patient selection as these procedures and techniques continue to evolve in the future, as well as understanding how these patients progress after their procedure. Stroke remains a devastating although fortunately rare outcome for aortic valve intervention. By understanding the risk factors that underly stroke, we hope to improve patient selection into different pathways and streams of management for aortic valve surgery or intervention and in the rare instances where stroke does occur we hope to understand how patients may progress and how treatment may help in their post-operative recovery, to reduce their burden or their quality of life.

What is the potential impact of your research?

As transcatheter aortic valve replacements (TAVI) expand to include lower risk and younger patients it is imperative to understand neurological injury associated with this procedure. An understanding of the causes may allow clinicians to develop new strategies to prevent or treat complications more effectively. An overview of this phenomenon may also allow clinical indications to be defined for TAVI to balance benefits and risk compared to alternative treatments such as surgical aortic valve replacement.

A total of 11 publications have been created through the research into this topic. Seven have been published and four are currently under review for consideration of publication in peer reviewed journals. and will be submitted towards the end of the year for the award of the degree of Master of Philosophy at The University of Sydney.

How has your scholarship from The Baird Institute helped you?

I have been fortunate enough to have been supported by a scholarship from The Baird Institute throughout my research and it has really assisted me in gaining access to quite high powered statistical software and hardware to analyse the data that we have collected. It has also allowed me to present my research at conferences both locally and internationally enabling me to share my ideas with my peers. By disseminating these ideas we hope to garner more interest and start more research in this area to help improve patient outcomes and patient safety in the future. I thank all those generous supporters of The Baird Institute for giving me this great opportunity to attain an MPhil and do life-saving research.

We warmly welcome Dr Sean Lal, Cardiologist, to the Board of The Baird Institute as Non-Executive Director.

Dr Sean Lal is an Academic in the Faculty of Medicine and Health at the University of Sydney and a Consultant Cardiologist at Royal Prince Alfred Hospital, sub-specialising in heart failure and cardiac MRI. He is also the Chair of the Heart Failure Council for the Cardiac Society of Australia and New Zealand.

Sean has a clinical and research interest in heart failure. For his PhD in this field, he was awarded a combined National Health and Medical Research Council (NHMRC) and National Heart Foundation (NHF) Scholarship, as well as the NHMRC and Royal Australasian College of Physicians (RACP) scholarship for research excellence.

Sean was also awarded a Commonwealth Endeavour Postgraduate Fellowship to Harvard University and Massachusetts Institute of Technology (MIT), where he undertook studies demonstrating the intrinsic regenerative capacity of the human heart following myocardial infarction; whilst also gaining clinical experience in acute heart failure management in the cardiac ICU at the Brigham and Women’s Hospital.

Sean is the Director of the Sydney Heart Bank at the University of Sydney, which is one of the largest biorepositories of cryopreserved human heart tissue in the world and something you will hear more of later in this newsletter. He is the Head of the Cardiac Research Laboratory in the School of Medical Sciences at the Charles Perkins Centre, which focuses on basic science and translational research into human heart failure.

To all the wonderful supporters of the Baird Institute, I send greetings and good wishes.

This has been a truly extraordinary year. Nothing quite like it since the scourge of the Spanish Flu in 1919, which even an old-timer like me did not witness.
The grim news of COVID brought frightful danger; the repeated warnings to wash our hands; the sudden appearance of hand sanitiser and facemasks; the daily reports on infection numbers; the terrible statistics of death and suffering; the images of emergency wards; the sudden urgency of ventilators to ward off the fiendish grip that this novel coronavirus takes upon the lungs, especially of elderly victims; the world of lockdown and isolation; the heroic work of the doctors and the nurses and administrative and support staff. All these images enter our minds and we will never forget them, even when COVID-19 has departed.

Everyone who has had close connection with The Baird Institute knows of the outstanding devotion of Australia’s medical, nursing and healthcare professionals. This message has recently been made vivid in our country and also in England. There, everyone from the Queen, the Prince of Wales, the Prime Minister, the ministers of state and all the ordinary citizens have joined in applauding the heroic work of the health professionals in the NHS. It has been the same in Australia. Fortunately, we took earlier urgent steps to act with resolution and determination. The consequence is that, at the time of writing this entry, whereas Britain has suffered nearly 26,000 deaths (165,000 infected) and the United States nearly 78,000 deaths (1.3 million infected), we have suffered about 97 deaths and many of those were infected on cruise ships.

This goes to show how important it is for governments and citizens to give active support to community responses to the necessities of healthcare that protect and save our lives. This is true of a completely new challenge such as COVID-19. But it is also true of heart and lung disease which remains a major health crisis in Australia and will do so long after COVID-19 has departed.

Tackling the endemic challenge of heart and lung disease cannot be effective if it is left to health professionals alone. As with COVID-19, it requires their leadership and highly professional care. But it also requires leadership from government. Leadership from civil society. And participation from citizens, patients, their families and friends.

If ever we needed to be taught the importance of community participation in responding to a very serious health crisis, COVID-19 has renewed that lesson.
Just as citizens came together to support each other in the battle against coronavirus, so we must come together to support each other and The Baird Institute in tackling heart and lung disease. The secret is the same. Brilliant medical leadership; the best of modern technology; candid information and explanations to the community; the use of modern media of communications; and strong political engagement.

We must turn the lessons we have learned from COVID-19 to the challenge of heart and lung disease. The Baird Institute deserves our support when the sound and fury of COVID-19 has died away.

With all good wishes,

The Hon. Michael Kirby AC CMG

Welcome to Professor Martin Misfeld

Co-Director of Research, Cardiothoracic Department, RPAH
We warmly welcome Prof Martin Misfeld. Martin is a Clinical Professor and Visiting Medical Officer in Cardiothoracic Surgery at RPAH. He is also the Co-Director of Research in the Cardiothoracic Department and a Senior Cardiothoracic Academic Advisor and International Proctor within RPA’s Institute of Academic Surgery. In addition, Martin has an Honorary Professorship at the University of Sydney.

Martin was born in Hamburg Germany, where he also went to medical school. He trained to be a Cardiothoracic surgeon in Luebeck near the Baltic Sea, in London and in Sydney. In 2009, he moved to Leipzig, in the former East Germany. The Leipzig Heart Centre is one of Europe`s biggest cardiac centres with more than 3,700 heart operations performed each year. Martin is a Professor and Senior Consultant and the clinical lead of minimally invasive surgery (MIS) at the Leipzig Heart Centre which is one of the pioneering centres for MIS. It became clear, that following a close relationship with the surgeons at RPAH, an international collaboration with a focus on MIS would be advantageous to further develop this surgical technique. As a result, Martin commenced part-time work at RPAH in 2019 and now divides his time between Leipzig and Sydney. The close collaboration between the Leipzig Heart Centre and RPAH is based on clinical work, offering the whole spectrum of MIS, the education and training of junior surgeons as well as the undertaking of clinical and basic research within an international network.

It is the strong belief of the Cardiothoracic Department that minimally invasive surgery and heart team decisions, where specialists from different clinical disciplines decide patient best treatment, will be the future and will be for the benefit of patients. Our collaboration enables us to teach, develop and evaluate these modern techniques as an international team who are at the frontline of cardiothoracic surgery.