European Heart Journal (2012) 33, 2109–2117
doi:10.1093/eurheartj/ehs216
The Socratic attic, where much of the future
of the stent was hatched
Although he makes no claim to be a pioneer, Prof. Patrick Serruys,
who recently retired as Chief of Interventional Cardiology at the
Thoraxcenter, Rotterdam, and his colleagues have taken the simple
idea of the stent to new heights, and in the process produced an
original paper once every few days, reports Barry Shurlock PhD
Once in a while medicine gets hold of a really big idea that opens
up completely new approaches to treatment. Penicillin was one of
these, and arguably, percutaneous coronary intervention (PCI) was
another. The 35 years since Andreas Grüntzig first opened a coronary vessel with a balloon catheter (1977) have seen the advent
of the specialty of interventional cardiology and an explosion of
subspecialties. Like surgeons, many interventionists now focus on
a single aspect of the heart, but those who make the greatest contribution are often able to embrace ‘the big picture’. Paramount
among these is Prof. Patrick Serruys MD, PhD, FACC, FESC,
who until recently was Chief of Interventional Cardiology at the
Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Now, at the age of 65, he must cede the top job, but has
no intention of slowing the pace.
Patrick Serruys
Over the years he has contributed to cardiology at the cutting
edge, first in the late 1970s, before the advent of interventional
cardiology, developing quantitative coronary angiography in collaboration with bioengineers at Erasmus University, where he holds
the Chair of Medicine. Then, like many others, he turned his attention to the problem of restenosis after PCI, which was blighting an
otherwise promising technique. Despite many attempts, pharmacology was not helping, and so he and his team turned to
mechanics and in 1994 published a randomized trial of
Pallamaz-Schatz bare-metal stents vs. balloon angioplasty. This is
one of the most quoted cardiology papers in the world [NEJM
1994;331:489–495] and was instrumental in the FDA approval in
the USA. Then in 1999, together with Dr Eduardo Sousa from
Brazil, he introduced the drug-eluting stent, before 7 years later
moving on to something he had long sought, namely, the fully
bio-absorbable drug-eluting stent.
Commenting on new developments, fresh from attending the
annual meeting of the European Association of Percutaneous Cardiovascular Interventionists, EuroPCR, May 2012 in Paris, he said: ‘If
we remain “plumbers”, it’s not a good message! Interventional cardiology is now merging with pharmacology, physiology and prevention. There are now 14 companies with products of this kind [bio
absorbable drug-eluting stents]—and the clinical signs are very
good—but we will have to wait until about 2015, when the
results from randomized trials in Europe, the US and Japan are
in, before we can be certain that liberating the vessel from a metallic insert is better. I think in the future we will be able to do
even more, to restore a larger part of the vessel, to refurbish
the whole vessel not just the occluded segment. With a 5 year
follow-up of biodegradable stents, using optical coherence tomography (OCT) we see a nice circular structure, “a golden tube”.
Despite his many achievements in interventional cardiology,
Prof. Patrick Washington Serruys, to give his full name (the Washington comes from a great-grandfather, who was once Belgian ambassador to the USA), is modest about his career. He said: ‘I have
never been a pioneer—I was always the second or third [in line],
checking if the pioneer is right, if it is the right therapy. I suppose
my paper of 1994, which has been cited more than 4000 times, is
the most important, though I have had 53 000 citations in all. I am
not entrepreneurial . . . not that I haven’t had ideas, but I have given
them to others . . . I have never tried to patent anything. In some
ways I think entrepreneurship is not compatible with the function
of the physician. And an inventor has to be obsessive, to have no
time for anything else, whereas I liked patients and could never just
stay on one thing. When I worked as a student in the 1960s with
the Nobel Laureate Sir Alan Hodgkin I knew I would never be a
basic scientist. We were studying nerve transmission in the giant
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: [email protected]
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nerve fibre of the squid, at the Marine Biological Association
laboratories in Plymouth, UK’.
Anyone with a high-profile research career is bound to receive
offers to move to other centres. Early in his career at the Thoraxcenter Prof. Serruys was invited to work with Dr Eugene Braunwald in the USA at the Harvard Medical School, Boston, but
decided that Rotterdam had all he wanted. More recently, he has
accepted a visiting professorship at the Imperial College of
Science, Technology, and Medicine in London, UK, working with
people at the Institute of Cardiovascular Medicine and Science at
the Royal Brompton and Harefield NHS Foundation Trust and
the Liverpool Heart and Chest NHS Foundation Trust, Liverpool,
UK. He said: ‘I visit for a day and keep in contact by phone and
email, fuelling their research programme in areas such as cell transplantation, nanotechnology and transcatheter mitral valve implantation. Imperial is an unbelievable scientific milieu—not many
Europeans know that we have on our doorstop something that
is equal to Massachusetts Institute of Technology (MIT) in Boston’.
For the next 2 years Prof. Serruys will be spending time with
holders of the Fellowship created in his name. He said: ‘Every
day I will spend about 3 h with them, like I always have. Until recently, I led a sort of double life, working in the catheter laboratory
by day, and writing papers with Fellows in the evening, often until
the early hours of the morning—many of them tell me that they
learned how to write a paper with me. But instead of working
from 8 am to 11 pm, it will be more like 9 am to 7 pm. It will
still be in my attic, with my library and all I need. I used to get
home at 7 pm and then at 8 pm the Fellows started banging on
the door. I love writing and the pleasure of Socratic dialogue and
don’t notice the time passing’.
This habit of a lifetime explains Prof. Serruy’s prodigious output of
papers, which in the last few years have appeared at the rate of
1 every 3 or 4 days. At the last count his name had appeared on
.1400 peer-reviewed papers recognized by the Institute of Scientific
Information, with .900 published in the last decade, 10 in the New
England Journal of Medicine, 16 in The Lancet, and 171 in Circulation.
His contributions were recognized at a celebration of his career at
the Thoraxcenter, Rotterdam, where he was presented with a
CardioPulse
huge tableau of all his papers that have appeared in the New
England Journal. The events were attended by .100 of the Fellows
who have worked with him and who all knew the ‘Socratic attic’
where so many of his projects were discussed and papers written.
Commenting on changes in the practice of cardiology ushered in
by interventional techniques, he said: ‘We basically used to diagnose like Sherlock Holmes and, as Paul Hugenholtz, first chairman
of the Thoraxcenter used to say, ‘provide fresh flesh for the surgeons’. Now we are semi-surgeons, so you have to have the characteristic surgical attitude. It’s a task for people who like to be
active, who want to see a change immediately—you open a
vessel and within 30 s the job is done. But it’s much more than
the job of a technician. Like the most beautiful of surgeons—the
Sir Magdi Yacoubs of this world—you must have a wide grasp of
many areas . . . histology, echocardiography, statistics, engineering
etc’.
Beneath the surface of a distinguished career lie some interesting
facts about Prof. Serruys that may account for much about his
ability to see the wide picture and explain his appearance on a
large part of the cardiovascular stage. For the person who has
chaired ESC working groups, founded Eurointervention, has an honorary doctorate from the University of Athens, has trained a team
of Japanese researchers (he calls them the Samurai), has been the
principal investigator in .57 clinical trials, has promoted 62 PhD
students, co-founded the academic clinical research organization
Cardialysis, co-edited the ESC Textbook of Cardiovascular
Medicine—and much else—grew up in the Republic of Congo
and was educated in Latin and Greek. He has a workload that
would daunt many, and is still looking out to a larger world.
One of his current projects is to try to spread the message of
interventional cardiology on the continent of his youth, by initiating
a new congress, Africa PCR. He said: ‘It’s a wonderful continent,
but one of the major problems will be to connect the Englishspeaking south with the French-speaking north’. As someone
who started speaking French and now speaks English like a
native, he is well placed to succeed.
Barry Shurlock, PhD
Introducing the National Institute for Health
and Clinical Excellence
England and Wales’ National Institute for Health and Clinical
Excellence ensures quality and cost effectiveness for drugs and
treatments in the NHS. Helen Jaques looks at what it does and why.
The key aim of the UK’s National Health Service (NHS) when it
was set up in 1948 was to provide healthcare to the whole
population, irrespective of wealth, using cash raised by taxation.
The National Institute for Health and Clinical Excellence (NICE)
was established in 1999 to make sure that the care provided by
the NHS is of the same high quality across England and Wales—
eliminating the postcode lottery in access to and quality of care
that had evolved in the UK—and that the care provided offers
taxpayers the best value-for-money.
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The roles of the National Institute
for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence initially
started out by recommending that drugs should be available on the
limited budget of the NHS. Its technology appraisal guidance aims to
ensure equitable access to new and existing medicines for the population and that the drugs used in the health service are clinically and
cost-effective. National Health Service organizations in England and
Wales are legally obliged to provide funding for medicines and treatments recommended by NICE’s appraisal board. In 2012 so far, the organization has made recommendations on 16 drugs, such as the use of
rivaroxaban and dabigatran etexilate for the prevention of stroke and
systemic embolism in people with atrial fibrillation. The National Institute for Health and Clinical Excellence also approves diagnostic and
medical technologies, the first output this year being its recommendation on new generation cardiac CT scanners for imaging in people with
suspected or known coronary artery disease.
In later years the remit of NICE expanded to encompass drawing up
evidence-based guidance on the most effective ways to prevent, diagnose, and treat disease and ill health. Overall, NICE has published
.500 pieces of best practice guidance on: clinical care in specific
disease areas (atrial fibrillation being one example); interventional procedures (such as off-pump coronary artery bypass grafting); cancer services; and public health (for example, prevention of cardiovascular
disease); with at least 100 further documents in development.
One of NICE’s most important types of guidance for practising
clinicians is its clinical guidelines, which provide recommendations
for health-care professionals on how best to treat and care for
patients with specific diseases and conditions within the limits of
the publicly funded NHS. The topics for guidelines are recommended
by the government’s Department of Health on the basis of a number
of factors, including the burden of the disease in the population, the
impact of the disease on public resources, and whether there is
inappropriate variation in how the disease is treated across the
country. Guidelines are then pulled together from the best available
evidence by health-care professionals, representatives of patient and
carer groups, and technical experts, with input from the public and
other stakeholders via national consultations. Published guidelines
are reviewed every 3 years to decide if an update is needed to take
account of new evidence on the topic.
The National Institute for Health and Clinical Excellence also publishes quality standards, which are groups of statements that set
benchmarks for highly effective, value-for-money, and safe care in
the treatment and prevention of various diseases and conditions.
For example, the standard for the prevention of venous thromboembolism, one of the first quality standards to be published since
their introduction in 2010, comprises seven statements such as:
‘All patients, on admission, must receive an assessment of venous
thromboembolism and bleeding risk using the clinical risk assessment criteria described in the national tool’. The organization
hopes to have published standards in 150 clinical areas by 2015.
On top of all this, NICE provides implementation and monitoring tools to support health-care professionals and organizations
in putting its recommendations into practice, manages NHS
Evidence—a hefty database that provides access to clinical and
non-clinical evidence and examples of best practice—and advises
on primary care and health-care commissioning.
Guidance for cardiovascular
disease
The National Institute for Health and Clinical Excellence has
almost 150 recommendations and pieces of guidance for cardiovascular diseases, drugs, interventions, and technologies that
cover 16 cardiovascular areas ranging from angina to varicose
veins. The organization is also in the process of developing
many new guidelines for cardiovascular conditions, with advice
on venous thromboembolic diseases due to be published this
summer, and is updating several previously published cardiovascular guidelines, such as its recommendations on secondary
prevention of myocardial infarction.
NICE cardiovascular disease guidelines by topic
Aneurysm (7 guidelines)
Hypertension (9 guidelines)
Angina (12 guidelines)
Arrhythmia (27 guidelines)
Ischaemia (6 guidelines)
Myocardial infarction (17 guidelines)
Arteriosclerosis (1 guideline)
Peripheral arterial disease (1 guideline)
Coronary disease (11 guidelines)
Embolism (12 guidelines)
Stroke (12 guidelines)
Thrombophilia (2 guidelines)
Endocarditis (1 guidelines)
Thrombosis (14 guidelines)
Heart failure (10 guidelines)
Varicose vein (2 guidelines)
Each of the clinical guidelines for cardiovascular disease introduces the disease, outlining its prevalence and burden on the
health service; spells out the key priorities for diagnosis, treatment,
and monitoring of the disease; and provides detailed recommendations, with notes on implementation and areas for more research
to further improve the evidence base on the topic. The guidelines
are advisory rather than compulsory, although doctors must consider what the guidelines recommend when deciding on the best
possible treatment for their patient.
What you need to know
Over the remainder of 2012, CardioPulse will be publishing
regular articles on the NICE clinical guidelines for cardiovascular
disease, starting with the guidance on hypertension. The articles
will provide some context as to why the guideline has been
developed; give an overview of the particular guideline, highlighting the main recommendations; and outline how the guideline
compares with corresponding European Society of Cardiology
EU-wide guidance.
We hope these articles will shine a light on best practice in
cardiovascular medicine in England and Wales and assist clinicians
with making the best decisions for their patients.
Helen Jaques, freelance medical writer and editor
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Scandinavia’s journal for cardiologists
and cardiothoracic surgeons
Scandinavian Cardiovascular Journal began as a journal for
cardiothoracic surgery, but joining forces with cardiology has
increased the impact factor and number of subscribers
Scandinavian Cardiovascular Journal was founded in 1967 as a Journal
for Cardiothoracic Surgery. It remained in that guise until 1999 when
it was changed into a cardiovascular journal. ‘It was thought that
the scope was too narrow to continue its existence’, says chief
editor Prof. Rolf Ekroth, who retired from his professorship as
a cardiothoracic surgeon at Sahlgrenska University Hospital,
Göteborg, Sweden 2 years ago.
The journal was founded by the Swedish Association for CardioThoracic Surgery and paid for by a legacy fund that was almost 100
years old. The fund was intended to support the publication of
science in the surgical field. After the cardiology association in
Sweden, the journal and the surgical society discussed making it
a joint publication, the journal expanded its scope. Today it is
the official journal of the Swedish Heart Association, the
Swedish Association for Cardio-Thoracic Surgery, the Norwegian
Cardiothoracic Surgery Society, and the Scandinavian Association
for Cardio-Thoracic Surgery.
‘The topics are cardiovascular, with a stress on cardio’, says
Ekroth. ‘Cardiac, including coronary disease, makes up more than
90% of what is published today’.
Before 1999 lung surgery was included but the field was
dropped when the cardiologists came on board. The journal is
published in English, both in print and online.
Readers come from all specialties associated with heart
disease including cardiologists, cardiac surgeons, radiologists,
and anaesthetists. More than 90% of individual subscriptions
are Scandinavian, almost exclusively through membership of
associations and societies. Very few are independent. The
journal also has institutional subscribers (libraries) from all
over the world.
The number of manuscripts received varies from year to year
but over the last 4–5 years it has been an average of 240 per
year. Nordic countries including the small Baltic republics submit
35% of the manuscripts, followed by China (,30%) and
Turkey (almost 10%). The remainder come from Europe, the
USA, and Canada. The acceptance rate is 25%.
In 2010 the impact factor was 0.895. It has hovered at 1 for
the past 5 years. When Ekroth started as editor .10 years ago,
the impact factor was just 0.4. ‘This reflects a period of decline
in quality when it was still a surgical journal’, he explains. ‘When
I started as editor it was very soon after the change in topic and
I think that the quality has improved’.
When Ekroth became editor in 2000, his strategy for improving
the journal was two-fold. The first issue was to increase the editorial speed from submission to publication because it was almost one
and a half years, sometimes more. He believed that improvements
in this area would make the journal more attractive to authors.
His theory was correct and a quicker editorial process has
boosted the number of submissions from 70 to 80 papers (including case reports) per year in 2000 to 230–240 papers per year.
The journal no longer accepts case reports, which means there
has been a substantial increase in submissions of original articles.
A second change he introduced was inviting external authors to
write editorials on interesting topics and writing provocative editorials himself. The goal was to kick-start discussions and motivate
readers to pick up and read a paper journal. ‘Many people are very
uncertain about the future of paper publications’, says Ekroth.
‘I thought that would be one way of making the paper journal
more interesting’.
The editorials have increased the journal’s profile in Scandinavia
to the extent that it is cited in daily newspapers one to two times
per year.
Since 1999 Scandinavian Cardiovascular Journal has had two sections, cardiology and surgery. Recently an experimental animal
section has been added and today there are three section editors.
The rest of the editorial team composed of associate editors
(roughly two from each of the Nordic countries of Denmark,
Finland, Norway, and Sweden) who each have an area of expertise.
Together with the cardiology editor Ekroth assigns papers to the associate editors who then contact reviewers. The section editors and
associate editors meet at least once a year to discuss editorial issues.
Looking forward to the future, Ekroth continues to have the
same vision and strategy for Scandinavian Cardiovascular Journal as
when he took the post of chief editor in 2000. The two purposes
of the journal remain that it is a forum for discussion and that it is
the place where authors can get good science published.
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The big question in his mind is whether the paper version will
still be available in some years’ time, and he is unsure of the
answer. ‘I don’t think very many people scan paper journals’,
he says. ‘The normal way for most researchers is to go to
PubMed with the intention to get information from a particular
field which they are interested in. If that’s what the large majority will do, what’s the place of a paper journal, I’m very
uncertain’.
Jennifer Taylor, MPhil
Guidelines and guesswork
With ever more guidelines being published, Lois Rogers looks
at their development and shortcomings
Evidence-based medicine is the catch phrase of the age. The drive
to prove that all interventions, all drugs, all pronouncements on
exercise and lifestyle regimes are made as a result of doctors
having an encyclopaedic knowledge of research findings, is a
growing pre-occupation for health-care providers and clinicians.
The truth, however, is that the practice of medicine is not nearly
as scientific as we all like to think.
The patients may not particularly care. There is plenty of
evidence that one of the strongest influences on health-care outcomes is a patient’s faith in the skill of the doctor, not the scientific
evidence for the value of the treatment on offer.
Despite the frequent triumph of faith over science, as pressure
grows on health-care budgets, the requirement for doctors to show
the benefit of what they are doing can only become more pressing.
But this is where the problem starts. In the face of this pressure
to provide treatments of proven benefit, there has been an
explosion of guidelines.
Cardiologists who are, by definition, treating one of the largest
and most complex disease areas, are particularly affected by this
worsening blizzard of instructions about what to do with what
conditions, and it is often not clear how much science supports
the advice they are being given.
Even if clinicians diligently search for a relevant guideline to assist
in the treatment plan for a particularly tricky patient, there is a real
risk the patient may deteriorate while the hapless doctor wades
through yards of print, searching for a relevant piece of advice.
This can only improve for the doctor with the information
technology now being developed.
There are already thousands of such guideline documents produced by a variety of learned societies, and the European Society
of Cardiology (ESC) is currently in the process of adding even more.
Last November it produced Guidelines on the treatment of
peripheral artery disease and the management of cardiovascular
disease in pregnancy, followed in December by Guidelines for
non-ST elevation acute coronary syndrome. This spring it has
produced two further sets of guidance on the prevention of
cardiovascular disease and the management of heart failure.
Further advice on how to deal with a plethora of other conditions is
likely to emerge from research evidence reviewed by the American
College of Cardiology (ACC) scientific meeting in March, and again
from the American Heart Association meeting in November 2012.
The ACC agenda has scheduled debating time to discuss the
conflict arising from guidelines produced by the different expert
bodies, and the relative weight given to different interventions by
the American College of Chest Physicians, the American Heart
Association, the ESC, and the ACC itself.
Time has also been scheduled for polite disagreements about
optimum low blood pressure, and optimum cholesterol levels;
which patients should be sent for percutaneous coronary intervention treatment and which ones should receive coronary artery
bypass graft procedures; not to mention a session on which
venous thromboembolism patient should receive anti-coagulation
therapy, which drugs should be used for how long, and how to
avoid post-thrombotic syndrome.
Udo Sechtam
Prof. Udo Sechtem, an eminent Stuttgart cardiologist and
spokesman for the ESC Guidelines Committee, freely admits
there is a problem. ‘We produce guidelines approximately
every five years and we look to see if any answers have been
produced to the questions left by the last set of guidelines’,
he says.
‘We often come up with recommendations based on expert
opinion rather than evidence, and there isn’t much we can do
about it. The strongest evidence is from large randomized trials,
but someone has to pay for them, and that is not something
society is willing to do’.
Meanwhile, a recent study led by Pierluigi Tricoci of Duke
University’s Clinical Research Unit, published in JAMA, provides
a stark analysis of the scale of what is almost a guidelines industry.1
Tricoci’s team investigated the evolution of 7196 recommendations contained in 53 guideline documents on 22 different topics,
produced between 1984 and 2008.
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Pierluigi Tricoci
They found that not only had the number of recommendations
proliferated dramatically, the strength of the scientific evidence
supporting them had actually diminished.
Of 16 guidelines that gave details of the evidence supporting
their recommendations, only 314 out of 2711 recommendations
within the 16 documents were classified as evidence level A—
that is, conclusions drawn from the results of multiple randomized
trials or meta-analyses.
Almost half of the total recommendations were based
merely on what experts generally believe is the right course of
treatment—unsupported by anything other than weight of opinion.
‘In current guidelines, level of evidence C—indicating recommendations based solely on expert opinion, case studies, or
“standard of care”—is the most frequent designation’. Tricoci’s
report said. ‘These findings point to consistent gaps in evidence
about medical practices and the need to generate the research
required to close gaps in knowledge’.
His report also points out the potential for conflicts of
interest where there is no real evidence base to support a recommendation. ‘Expert clinicians are likely to receive honoraria, speakers’ bureau, consulting fees, or research support from industry’, it
says. ‘It is difficult to quantify the effect of conflict of interest in a
guideline-writing process . . . the perception among guideline
readers that financial ties may introduce significant bias in guideline
recommendations has been noted’.
Not only that, as Sechtem points out, there is a real problem in
raising funds for clinical studies that are not going to lead to
increased sales for a particular product. Trials comparing the
relative merits of two similar treatments almost never happen.
A small glimmer of hope lies in an initiative by the American
National Heart Lung and Blood Institute (NHLBI), which is in
the process of awarding grants to a variety of research projects
attempting to answer some of the central outstanding questions
affecting the practice of cardiology, but answers are not expected
any time soon.
The latest batch of ESC Guidelines have tried to address these
on-going concerns, with at least half of their recommendations
derived from trial evidence, but pending results from the NHLBI
initiative, it is not clear how much they will help clinicians trying
to decide how best to treat a patient whose condition has not
been investigated by clinical trials.
The scope for disputes between experts, therefore, looks
unlikely to diminish very much in the immediate future.
Lois Rogers, international commentator on health science and social
policy issues
Reference
1. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009;301:831 –841.
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Germany’s largest heart centre opens
for business
Patient care and the advancement of medical science are the top
priorities for the University Heart Center Freiburg—Bad Krozingen
University Heart Centre Freiburg-Bad Krozingen
Freiburg University Medical Clinic
Germany’s largest heart centre, the University Heart Center
Freiburg—Bad Krozingen, opened its doors to patients on 1
April 2012. It was created from the merger of the University
Cardiovascular Center Freiburg and the Heart Center Bad
Krozingen. Some 1500 staff will provide cardiology, angiology,
and cardiovascular surgery to 20 000 patients each year. Personnel
will be shared and there will be common curricula for students and
for physicians in training.
The new centre has five departments: cardiac surgery, paediatric
cardiology, translational research, and two departments of cardiology and angiology. These are based in two locations that are
30 km apart. The vision is that in the long-run emergency
cases will be dealt with at both locations equally well. Specialties
Bad Krozingen Heart Center
will likely emerge in each centre and be allowed to grow over
time. A possible scenario could be that the sicker patients and
those who need more interdisciplinary treatment will preferably
be treated in Freiburg.
The department for translational research was created by
the faculty of medicine in Freiburg for the merged heart
centre and is looking to recruit a chair with an international
reputation.
There were a number of reasons behind the merger, some
practical, and others political. Combining two good institutions
leads to a higher institutional volume of procedures and merges
the experience of doctors, which should lead to a better quality
of care especially for rare diseases.
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Christoph Bode
Franz-Josef Neumann
The combined institution is larger and makes it more visible on a
nationwide, European, and international scale. The centre already
attracts 95% of patients in the region. But Freiburg lies on the
border with Switzerland and France and it is hoped that
increased visibility will get patients to cross borders for their
health care.
‘It is not the intent to merge and optimise economy by abolishing things here or there, or doing them only at one of the two
centres’, says Prof. Christoph Bode, director of the Department
for Cardiology and Angiology I in Freiburg. ‘It is the declared aim
to grow’.
A political reason behind the merger is that a private heart
centre like the one in Bad Krozingen becomes more valuable if it
is attached to an academic centre. ‘A university centre always
has something going for it in terms of quality, in terms of being
at the cutting edge of science [and] being neutral in terms of the
economy that is behind medicine’, he says. ‘Because those are government run places and not for profit’.
Bad Krozingen has a history of conducting clinical research, but
Prof. Franz-Josef Neumann, medical director of Cardiology and
Angiology II at Bad Krozingen, says it will benefit from the basic
science research at Freiburg. ‘On the other hand I feel that the
Freiburg side can benefit from the large patient numbers and
enormous clinical experience at our centre’, he says.
He adds: ‘Bad Krozingen is already among the largest
centres in Germany in cardiology [and] we have the benefit
of large patient numbers which gives us strength in clinical
studies. It will also give us more experience with rare cardiac
diseases’.
Until the merger the academic centre at Freiburg and the private clinic
at Bad Krozingen had different philosophies, ways of working, and types
of patients. But Bode believes the two can learn from each other.
‘There are things that the former university department can learn
from a higher throughput centre in terms of organisation and in
terms of getting things done’, he says. ‘And there [are] also a lot of
things that will influence everyday medicine in the higher throughput
centre by looking very closely at people - not only looking at one
organ but looking at all of the problems that a patient has’.
He believes that patients on both sides of the merger will
benefit. Coming from the university side of the merger, he thinks
the larger benefit will be for patients who were formerly not
treated at the university.
Cardiology and Angiology II is located in Bad Krozingen.
Cardiology and Angiology I is primarily located at the university
in Freiburg, but part of it is located in Bad Krozingen. ‘This is
where the development of a common philosophy will start’, says
Bode. ‘When that has begun at one of the locations we will
spread it throughout the whole heart center to two locations’.
Both Bode and Neumann agree that patient care and the advancement of medical science are the top priorities. But the new
centre is not guaranteed of success—it will require compromises
and hard work.
Bode says: ‘We have a unique chance to build something new but we
have to be very cautious—because we’re coming from two good institutions—not to build something new at the cost of giving up valuable,
proven and tested ways of doing medicine and being organised’.
Jennifer Taylor, MPhil
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Book review
Pulmonary vascular disorders
Editors: M. Humbert, R. Souza, G. Simonneau
Publisher: Karger
ISBN: 978-3-8055-9914-6
Progress in Respiratory Research series
Editor: C.T. Bolliger
Vol. 41
Pulmonary vascular disorders encompass different conditions
leading to an elevated pulmonary artery pressure, along with
pathological dysfunction affecting all layers of the pulmonary
vessel wall. Knowledge about the pathogenesis, pathophysiology, clinical presentation, and prognosis of pulmonary vascular
disorders has made substantial progress during the last two
decades. This has enabled the heterogeneous pulmonary vascular
disorders to be classified according to pathological aetiology and
therapeutic response into five different classes during the WHO
conferences in Venice 2003, and at Dana Point in 2008.
Along with a better understanding of the disease brought
about by detailed scientific investigations all over the world, effective medical therapies were developed for patients classified
as having WHO class I pulmonary arterial hypertension. With
the development of surgical pulmonary endarterectomy,
patients in WHO class IV affected by chronic thromboembolic
pulmonary hypertension can even be cured. However, despite
the undoubtedly paramount importance of these developments,
the majority of pulmonary vascular disorders remain incurable
and for some patients even therapies to effectively improve
symptoms or disease progression are lacking. Therefore, diagnosis, classification, and management of pulmonary vascular disorders remain an on-going challenge for health-care providers,
scientists, and especially for the affected patients.
The book ‘Pulmonary Vascular Disorders’ comprehensively
addresses the whole diversity and complexity of its entities
from the pathobiology background to the epidemiology, diagnosis, and treatment. It is carefully divided into 28 chapters dealing
with all major aspects, classes, subclasses, and managerial functions of pulmonary vascular disorders. Each chapter reviews
the current knowledge in the field and can serve as a valuable
overview for specialist or didactic teaching for physicians and
scientists who are not yet familiar with certain aspects of the
entity. All chapters together form a stand-alone volume for
every health-care provider interested in this exciting and
rapidly developing field. This book provides a comprehensive,
profound, and valuable practical resource, even in the modern
era of fast-moving internet-based knowledge acquisition: just a
real joy to read and look-up whatever be the topic needed in
the field.
Silvia Ulrich, MD
CardioPulse contact: Andros Tofield, MD FRCS FACEP, Managing Editor CardioPulse, EHJ. Email: [email protected]