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Eur J Cardiothorac Surg 1999;14:223-228
© 1999 Elsevier Science NL
Editorial |
Widenmayerstrasse 7, D-80538 Munich, Germany
Received 11 July 1998; accepted 21 July 1998.
The attention of Western observers of Russian cardiac surgery traditionally has focused on two cities, Moscow and St. Petersburg. This is where Russian cardiac surgery first emerged, where the big names reside and where large numbers of patients are being treated. Beyond these cities, Russian cardiac surgery has remained an enigma for Western researchers perhaps with one exception: the large Research Center of Circulation Pathology in Novosibirsk, formerly headed by the late Professor E.N. Meshalkin. This institution had attracted the attention of Western surgeons early on because of the large volume and variety of cases operated there using surface hypothermia.
Cardiac centers visited
In order to shed some light on Siberian cardiac surgery as it is practiced today, the author, as delegate of the European Association for Cardio-thoracic Surgery, visited six centers in May and June 1998: the Regional Hospital #1 in Ekaterinburg (Dr. A. Michailov), the Regional Hospital #1 in Chelyabinsk (Dr. V. Prikhodko), the Kemerovo Cardiac Center (Professor L.S. Barbarash), the Institute of Cardiology in Tomsk (Professor V.M. Shipulin), the Institute of Circulation Pathology (Professor E. Litasova) and the Regional Cardio Center (Dr. J. Bravve), both in Novosibirsk.
All of these cities are located along the Trans-Siberian Railroad line at geographical latitude 55±2°, corresponding to that of Copenhagen. That stretch of land is enormously rich in minerals and coal, has giant industrial conglomerates, but also is haunted by the memories of the Gulag. While Ekaterinburg and Chelyabinsk are located just beyond the Urals, the other cities lie in central Siberia. The time difference between Kemerovo and Central Europe amounts to 6 h!
Ekaterinburg, one of the historical gateways to Siberia, now is an important industrial site. Even more so, Chelyabinsk is the heart of the Russian metallurgic and, more recently, the atomic and space industry. A single factory in that city, now vacant, has produced 2 million chain tractors and 80 000 tanks(!), thereby playing a decisive role for the demise of the German army in World-War II. One of the three classical trade routes of Siberia is the Ob river. On it shores and that of its tributary, the Tom, three important cities are located: Novosibirsk on the former, Kemerovo and Tomsk on the latter river. Novosibirsk is a large industrial town, world renowned because of Akademgorodok, a key center of Russian science, located in a lovely suburban forest. Tomsk was founded more than 400 years ago as the center of Siberian trade, settlement and ultimate conquest. It is a beautiful city now, teeming with students. The city also includes a top secret complex of advanced science institutes, supposedly mainly military. Conversely, Kemerovo, the center of the vast Kuzbass coal region, only goes back to the early 1930s and is famous for its chemical plants. It recently attracted international attention because of miners' strikes blocking Siberia's life line, the Trans-Siberian Rail line.
The main purpose of this journey was to assess the present state of these units, their future potential, and their desire for a closer cooperation with Western clinics of cardiac surgery. On my way home I visited five cardiac centers and one pulmonological center in St. Petersburg: the cardiosurgical service of the Russian Military Medical Academy (Professor Y.L. Sevchenko), the Regional Hospital #1 (Dr. J. Schneider), the Childrens' Hospital #1 (Dr. V. Lubomudrov), the Scientific Research Institute of Cardiology (Dr. V.K. Novikov) and the cardiac and pulmonological services at the Research Center of Pulmonology (Dr. V. Leichenko and Professor Y. Levashev). This part of my visit, in a way, served as a comparison for my experiences in Siberia.
Operative profile
Presently, a significant volume of open heart surgery using extracorporal circulation in the vast territory of Siberia with its population of 50 millions, is performed in 10 centers. Going from West to East these are located in the cities of Ekaterinburg, Chelyabinsk, Omsk, Novosibirsk (2), Kemerovo, Tomsk, Krasnojarsk, Barnaul and Irkutsk. The number of procedures using the heart-lung-machine was approximately 2000 in 1997. To this an additional 280 open heart procedures under surface hypothermia must be added for a total of 2300, corresponding to some 50 open heart operations per million of population. Clearly, the major portion of this type of surgery is carried out in Moscow (approx. 3000) and St. Petersburg (approx. 1000). Surgery for rheumatic heart valve disease still plays a major role exceeding more than 50% in some centers. Likewise, there is an abundance of operations for infective endocarditis. This is followed by corrective operations for congenital heart disease in children and adults. Units specialized in surgery on newborns and infants only exist in Moscow, St. Petersburg and Novosibirsk. More recently, coronary surgery has grown in importance but presently still is in a developmental stage in most units. Only 5 of the 11 cardiac centers visited in Russia perform more than 100 such operations annually. Notably, the Regional Cardiac Dispenser in Novosibirsk was designed to concentrate on coronary surgery, but only is beginning its program.
Structure of cardio-surgical units
Divisions of anesthesiology, extracorporeal perfusion (commonly performed by physicians!) as well as interventional cardiology are integrated in the institutions devoted to surgery. The latter usually have two cardiac catheterization facilities at their disposal. There are, however, surprisingly large conservative cardiology divisions which are separate. Some of the centers, in Soviet times, were selected to perform a variety of anti-arrhythmic interventions (e.g. Ekaterinburg and Tomsk), including pacemaker implants as well as surgical and catheter ablation of arrhythmic foci. Laboratory facilities are included in the surgical departments. Practically all centers are engaged in vascular surgery as well; general thoracic surgery is always kept separate.
Administration of cardiac centers
The administrative control of the Russian centers performing cardiac surgery is amazingly varied, reflecting, in part, the old Soviet idea of centralization. Thus, there are cardiological institutes belonging to the Ministry of Health, the Russian Academy of Medical Science and the Ministry of Military Affairs. All such centers have an academic profile and are engaged in scientific research of varying intensity. A good example of highly sophisticated research on cardiomyoplasty was observed in Tomsk. The Kemerovo unit has produced interesting epoxy-treated heterograft valves which were shown to be less prone to calcification than the glutaraldehyde version. Other centers are governed by cities and regions (Oblasts). Their heads commonly participate in student teaching at the respective medical school. Hospitals where cardiac surgery is located customarily are directed by a physician-administrator who may be a cardiologist, cardiac surgeon, anesthetist or other specialist.
Under the Soviet system individual health insurance did not exist. Presently, some major industrial companies offer insurance plans and a few patients enjoy private coverage. The cash flows to cardiac centers from different and sometimes overlapping sources. It varies considerably with the relative prosperity of the hospital carriers and the insight of the persons responsible for the need of cardiac surgery (political figures in Moscow, governors of the Oblasts, city majors, physicians heading the hospitals). Their decisions, as one might imagine, often appear quite irrational even to the people on site. In any case, financing of cardiac surgery does not seem to follow consistent planning and, in general, is inadequate.
Buildings
The centers of cardiac surgery in Siberia were founded in the Soviet period and, to our surprise, had been planned quite luxuriously even by Western standards ( Fig. 1 Fig. 2 ). This applies to buildings, operating rooms, which generally are much larger than those in the West (up to 100 m2!), to patients wards, corridors and outpatient departments. Some have rehabilitation facilities and even hotels at their disposal. Other units (Chelyabinsk, Kemerovo) are crammed into out-of-date regional hospitals in anticipation of newer buildings to be erected or completed. In the latter city, a huge cardiac center was started 10 years ago but its surgical section, including eight operating rooms, deplorably still awaits completion. The two centers in Novosibirsk and that in Tomsk have been or presently are undergoing renovation and therefore are in an adequate architectural state. Conversely, the other three Siberian units visited are in great need of fundamental refurbishing, especially with respect to hospital hygiene. Importantly, none of the centers in Siberia (and St. Petersburg) have modern air conditioning or filtering in the operating theaters and intensive care units.
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The equipment and apparatus available again varies greatly from place to place. On the diagnostic side, one or two cardiac catheter facilities generally are available. The echocardiographic equipment appears adequate, but transesophageal probes often are missing. The operating room equipment varies from totally insufficient and obsolete to reasonably modern. Some operating tables I saw date stem from pre-war times ( Fig. 3 ). Electrical cables run across the floor. Operating rooms tend to be crammed with objects which would have to be placed outside according to modern standards of hygiene. The apparatus used in the operating rooms and intensive care units comes from a variety of sources, mainly Western, but also some Russian, and often makes for a real potpourri ( Fig. 4 ). It generally is far below actual needs. In the optimal case (Novosibirsk, Tomsk) the centers were able to buy a more or less uniform set of heart-lung and anesthesia machines, respirators and monitors while in others the apparatus appears quite random, originating from a variety of Western benefactors and/or from discount sales by individual industrial companies. As a result, each unit runs busy mechanical, electric and electronic workshops, ingeniously trying to make up for the almost universal lack of spare parts. All heart-lung machines are of Western origin (Gambro, Jostra, Stöckert, Sarns) but many are quite out-dated.
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One area of great concern that severely limits the volume of cardiac surgery in Siberia is the lack of funding for disposable equipment including oxygenators, tubing, cardioplegia sets, vascular grafts, cardiac catheters and especially suture material, all of which must be bought in the West. Since hospitals generally supply only a fraction of the cost of an operation, this bottleneck is overcome by a variety of ways: an amazing number of procedures are carried out by palliation rather than correction. Maximal use is made of interventional cardiological means both in congenital and acquired heart disease. Interestingly, the Center of Circulation Pathology in Novosibirsk performed 280 of its 750 open heart operations during circulatory arrest in surface hypothermia. Until recently, the Tomsk center also had used this modality. According to the present director of the former unit, Professor Litasova, more than 12 000 open heart procedures, including valve replacement, thus far have been performed in this way. I was able to observe the operation on a 5-year-old child with ventricular septal defect and septal aneurysm carried out during a 37 min circulatory arrest at 24.6°C. Additional brain cooling, cardioplegia and exsanguination is used routinely. Arrest times up to 50 min and even longer are seem to be tolerated according to a recent in-depth follow-up study. Presently, a device for selective intraventricular rewarming is being tested in order to overcome the need for laborious prolonged cardiac massage. Whatever view one might take of this approach, it was made clear that without it the vast number of patients so treated never could have undergone cardiac surgery.
The lack of equipment and apparatus is well illustrated in this list:
Funding
An open heart operation under extracorporeal circulation without inserting implants produces net costs of US$ 5000–6000 in Russia. In former days, the respective hospital carrier would pay for the whole procedure and this sometimes still is true today. The patient, however, might end up being operated upon with a non-disposable foam oxygenator in use since the sixties. The tubing required for extracorporal circulation as well as cardiac catheters and cannulae then will have been resterilized repeatedly. In other instances, the patient pays a basic fee of US$ 1000, the hospital carrying the rest. Finally, the easiest access for patients to open heart surgery is for him to buy all the equipment necessary (including angio films and cardiac catheters) either in the hospital supply shop or in a downtown store! If a heart valve prosthesis is required it likewise may be bought by the patient ($ 2000 for a Western, $ 500 for a Russian valve). Purchase of equipment by the patient is widely practiced and, in fact, has prevented temporary collapse of the annual operative program in at least two Russian centers I visited.
Personnel
Another problem hampering the scope and progress of cardiac surgery in Russian rests in the personnel. By Western standards the ratio between the number of surgeons and the generally small operative case load appears disproportionate. Aside from this, Russian cardiac surgery traditionally has been overspecialized with separate teams for infants, children, valve and coronary patients as well as those needing anti-arrhythmic surgery, therefore requiring a larger number of surgeons than in the West. Despite this degree of specialization, there is no board-recognized training in cardiac surgery or its subdivisions. Nevertheless, all of the operations by senior surgeons I observed, were carried out in up-to-date techniques.
The salary of physicians is ridiculously low (US$ 200–300/month), but seems to be augmented by occasional donations from patients. Everyone seems to own a Datcha where a small plot serves for the supply of agricultural goods – quite helpful, if salaries do not arrive! In contrast to the high proficiency of surgeons and head nurses, the general nursing and other personnel often does not measure up to Western standards. Their difficult working conditions are often also crushing their motivation. This relates to low salaries (US$ 100–150/month) as well as to shortage of housing and efficient transportation. Salaries sometimes are not paid for months, housing is expensive and generally is not provided by the hospital. Nurses may be forced to live in distant quarters with impossible transport facilities. As a result, and also due to the frequent breakdown of equipment and apparatus, only one case per table and day can be operated, thereby preventing an adequate use of operating facilities. Outside the regular work day every effort is voluntary. Where it not for this problem and the general lack of funding, most centers could operate on many more patients.
Although not the object of this report, my experiences in St. Petersburg in many ways equaled those made in Siberia regarding both the facilities and equipment available and the limited case loads of individuals centers. There are, however, certain differences: the cardiac surgery services of both the Military Medical Academy and the State Research Center of Pulmonology have a long tradition, going back to the founders of Russian cardiac surgery, Professors Kuprianov and Uglov. Four of the five St. Petersburg cardiac surgery units visited perform more than 200 open heart operations annually, the former more than 400. One center, however, had to close down for the summer for the reasons given above. Two of the St. Petersburg units (those of Drs. Lobumudrov, Novikov and Schneider) have established strong ties with renowned Western European and US-American partners.
Conclusions
Summing it up, a Western observer only can marvel at the enthusiasm and optimism of our colleagues in these far-off places. Everyone realizes that the momentary conditions will be extremely difficult to overcome and sees his hopes only in the economic revitalization of Russia. Siberia in particular potentially is one of the wealthiest regions in the world. Aside from funding, a definite political will for regenerating and efficiently operating the peripheral centers of cardiac surgery seems mandatory at this stage. In this context, I was given several opportunities to converse with the media, the results appearing on radio and television. My main purpose in such interviews was to highlight the fact that cardiac surgery is not so expensive as generally claimed when compared with the costs of endless conservative treatment – an old and familiar argument to senior Western European cardiac surgeons!
Clearly, the general lack of funds for improving and building hospitals and for procuring modern equipment is ultimately the responsibility of the Russian authorities. Nevertheless, punctual material help from philanthropic organizations and industrial companies has been and hopefully will be forthcoming. There are, of course, other potential sources: many Western surgical centers have large stores of surgical equipment and apparatus which, although termed `outclassed', are functioning perfectly well. As an example, tons of such material were shipped to Kemerovo, Russia, and to Kaunas, Lithuania, by Dr. M. Bugge of Salgrenska Hospital in Gothenburg, Sweden, under the auspices of the EACTS. Since the recipient is to pay for transport and sometimes (unbelievably) for taxes as well, such donations must be well selected. The author will gladly provide lists of equipment in great need at individual centers.
In contrast to our limited possibilities for material help, there are many ways of providing educational assistance. This has been practiced by the EACTS, via its East European Committee as well as by philanthropic foundations and individual hospitals both in Western Europe and in the United States. Thus, visiting professorships and visits of whole teams, including surgeons, cardiologists, anesthetists, perfusionists, and even ICU nurses and managers have been were financed by our Association. The help of several industrial firms in this endeavor is greatly appreciated. In the course of time it has become apparent to us that contracts of long-term cooperation between Eastern and Western clinics should be aimed at primarily. A strong desire for such assistance was voiced by all my hosts in Siberia and St. Petersburg. As it turned out, several Siberian clinics already have such ties (e.g. Tomsk with Bergamo and Berlin, Ekaterinburg with Hamburg, Kemerovo with Gothenburg). Such cooperation clearly must be strengthened in the future. The EACTS will do its best to provide the necessary financial and logistic support. Finally, several surgeons encouraged me to motivate Western cardiac surgeons to participate in teaching symposia on special topics of their choosing. This suggestion should be seriously pursued.
Our colleagues in these cardiac centers gave your EACTS representative a most hearty welcome. They treated me with great openness and friendliness, sometimes mixed with curiosity. After all, Western cardiac surgeons had never visited some of these clinics. Despite their limited means, my hosts produced admirable extracurricular programs, showing me the interesting sites of their vast environment, including trips to wonderful fields, forests, huge rivers, cultural sights and often defunct enormous industrial complexes. All of my hosts graciously provided excellent interpreters for either English or German.
In summary, it was a most interesting journey and I wish to thank our Russian partners with all my heart for their welcome. In view of the overwhelming need for support and encouragement our colleagues in the Russian periphery have, I wish to encourage active and enterprising Western Europeans to join the efforts of the EACTS. Considering our own post-war past, where massive help was so graciously provided to us by the Americans, I feel we are obliged to show our flag in the European East, particularly in the countries of the former Soviet Union.
Acknowledgments
My cordial thanks for their help with this manuscript go to Professor V. Alexi-Meshkishvili, Berlin, Y. Schneider, St. Petersburg, and again to my dear friend Dr. C. Hiebert, Maine Medical Center, Portland, Maine.
This article has been cited by other articles:
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  H. G. Borst The hammer, the sickle, and the scalpel: a cardiac surgeon's view of Eastern Europe Ann. Thorac. Surg., June 1, 2000; 69(6): 1655 - 1662. [Full Text] [PDF]
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