Steven Fremes Appointed to a Second Five Year Term as the Dr. Bernard Goldman Chair in Cardiac Surgery

Steve Fremes

In his successful 5 year review of his first term as the Bernard Goldman Chair of Cardiac Surgery at Sunnybrook, Stephen Fremes described himself as a clinician researcher, rather than a clinician scientist, illustrating his clinical studies on arterial revascularization to improve coronary bypass patency. His emphasis is on active practice. Following initial studies with Richard Weisel on myocardial protection, his international reputation grew based on studies on grafts to revascularize the coronary circulation. He is proudest of the recent guidelines issued by the Society of Thoracic Surgery. In contrast to the earlier guidelines by the American Heart Association, the American College of Cardiology and the European organizations, the STS elevated radial artery revascularization to a class 1 indication. This was a culmination of his recent studies, now in press.

Steve has also worked myocardial protection using Levosimendam, an FDA approved industry-funded study. 20% of the sites for this study are in Canada, where the recruiting has been excellent. Steve is the national lead for this study which will be presented at the American College of Cardiology meeting in spring 2017.

He is also at the transition from a pilot to a large study of selenium as an antioxidant in the repair pathway for the prevention of major organ injury following higher risk cardiac surgery. Non-randomized clinical studies have been positive and the pre-clinical studies very promising. The pilot study has been completed and training is under way at the sites that will begin entering patients in the fall. Selenium levels fall after cardiac surgery, a promising lead. There may also be a dietary factor. Germany and Canada are the two countries that will recruit patients for the selenium study.

The third theme of his clinical research has been minimally invasive cardiac surgery. TAVI (transarterial valve implantation) is the principal focus. “We were early adopters and are now the 2nd or 3rd largest centre in Canada performing TAVI, after Vancouver and Quebec City. The research is collaborative. Dr. Shyam Radhakrishnan and Dr. Harindra Wijeysundera are very active in this work. We have currently completed enrollment into a moderate risk (in contradistinction to inoperable or high operative risk) aortic valve disease patients. We were the top Canadian recruiter in the randomized trial. There are now 2 low risk cohort, i.e. less than 3% predicted operative mortality, studies approved ; the studies are only operational in the US at the present time, but will eventually be opened in Canada.”

The take- home message is that TAVI is very effective in high risk patients and adequate in moderate risk patients. An important question is about long term valve durability and it will take lower risk data to address this. The higher risk patients who have been primarily treated so far, cannot be counted on to answer this question as the patients’ longevity is limited because of advanced age and co-morbidities. There is currently equipoise for low risk patients. The youngest patients who have bicuspid valve disease are being treated by TAVI off label. This is probably too big a step at this point in time, as these are very low risk patients for open surgery and probably will not be improved by a catheter - based intervention.

“I’ve had excellent research fellows, typically from the Surgeon-Scientist program but also including international post-doctoral MDs. Currently, Saswata (Sas) Deb is in his 5th year. He is a PhD student with multiple awards. He will complete his PhD in this academic year. Derrick Tam is joining me in July, focusing his work on aortic stenosis, and Reena Karkhanis, who has been working with me as a research assistant will be starting as an MSc. The Schulich Cardiac Program has embraced the less invasive approach to heart disease including the TAVI work, but also the Mitral Program with Gideon and Eric Cohen in the lead, and less invasive CABG (Coronary Artery Bypass Graft Surgery) with Dr. Fuad Moussa (surgery), doing hybrid revascularization.

“EVAR has flipped vascular surgery into the catheter based minimally invasive category. The change has not been so significant in cardiac surgery, but it will be for aortic valve replacement, probably up to 50%. The question is open regarding mitral valve disease. There are many products available and lots of first-in-man reports. We have been approached for 2 such studies, but Gideon and Eric are currently using the MitraClip – based on the Alfieri procedure.”

Q: What do you do besides patient care and research?

A: I am a bad golfer on weekends. My wife Jill and I are raising three kids, and I am enthusiastic about theatre.

Q: What do you read?

A: Principally, the Economist. I work a lot on my research, especially now after finishing a long period as the Chief of Service. With less administration, there is less frustration, and more academic time.

Q: What do you anticipate in your future?

A: I will be consulting about some of the “imponderables”, i.e. what will be the future of acquired heart disease treatment as the population ages. The direction is unclear regarding surgery versus medication. Pharmacotherapy will certainly be a big factor. The PKS9 inhibitors, though currently very expensive, will likely be a major player. Interestingly, our children may be less healthy than we are because of the obesity and diabetes epidemics. This is not a cheery trend except to the companies that treat heart disease. Europe, because of its more rapid approval speed, is now outpacing the U.S. and North America in introducing new drugs and technology.

MM