German Heart Centreof the State of Bavariaand the Technical University Munich

Patient’s Guide

PublisherGerman Heart Centre Munich

www.dhm.mhn.dedhm@dhm.mhn.de

Press OfficerRobert Siegert

Design and Layouticom new mediaIckstattstraße 1680469 München

www.icom.deinfo@icom.de

PhotographyHelena Soikicom

2nd edition May 2004

German Heart Centre MunichLazarettstraße 36

80636 MünchenGermany

Telephone +49 (0) 89 1218-0Fax +49 (0) 89 1218-3053

Welcome

Vision

How the heart works

Department of Cardio-Vascular Surgery

Department of Cardiac and Circulatory Diseases

Department of Paediatric Cardiology and Congenital Heart Disease

Institute for Anesthesiology

Institute for Laboratory medicine

Institute for Radiology und Nuclear Medicine

Patient Care

Robotics: Computer-aided surgery at The German Heart Centre

Ultra fast-Cardiac-CT

Sana Kliniken-GmbH – Private Management

Total Quality Management (TQM) – a puzzle with nine pieces

McDonald’s Kinderhilfe

Friends of the German Heart Centre Foundation

A-Z

Numbers of patients and procedures

How to reach us

Information on the Internet

Contact

Table of content

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Dear Reader,

Turning through the pages of this bro-chure, you will understand very quick-ly, what a valuable asset the GermanHeart Centre Munich is to the Free Sta-te of Bavaria. The new department buil-ding which was constructed at a cost ofmore than € 115 million and put intooperation in 1996 lays optimal groundsfor a modern and patient-oriented top-level medical care. Highly qualified,committed and motivated staffs in allsections of the establishment doeverything they can to ensure the de-sired medical success for the patientsunder their care also with the most se-rious illnesses. For instance, the excel-lent treatment opportunities and suc-cess for infants and children are highlyimpressive. Thus, the 11.111th pediatriccardiac operation could be celebratedof late at the German Heart Centre Mu-nich with a grand children party. Withthis worldwide unique figure, the estab-lishment occupies a leading positionalso by international comparison.

However, the leadership status of theGerman Heart Centre Munich is notconfined only to medical activities.The department is involved in researchand teachings at university levelthrough a long-term working coopera-tion with the Technical University ofMunich which spreads over severalyears and is supported by us on an-nual basis with about € 2.5 million. Thisintensive scientific exchange enables

the decisive contribution by the GermanHeart Centre, to the further develop-ment of the treatment of cardio-vascu-lar and circulatory diseases which con-tinue to count among the most frequentcauses of death not only in Germany.

Despite the well known constraints inpublic funds and the difficult financialconditions of the health system, theFree State of Bavaria continues to becommitted to top-level performance inmedicine. The purchase of the techno-logically highly innovative ultra-fastcomputer-tomographs for the German

Heart Centre Munich which enablesprecise picture transmission withinthe shortest possible time underscoresour commitment. We will also do ourutmost in the future to consolidateand further expand upon the peakposition attained by the German HeartCentre Munich .

On this note, I wish the establishmentmore success, rapid and effectiveassistance to all patients in the estab-lishment.

Munich, in December 2003

Dr. Thomas GoppelBavarian Minister of Statefor Science, Research and Arts

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Since its foundation in 1974 as the firstheart centre in Europe, it has served asa model for other institutions numeroustimes. The new medical concept of treat-ing patients of all ages with all typesof cardiovascular disease at one facility

has proved to behighly effectiveand has becomeaccepted in otherareas of medicine.

The guiding principle of the hospital isto consolidate at one location the va-rious medical branches required forthe diagnosis and treatment of cardio-vascular disorders, thus providing op-

timal patient care through close inter-disciplinary cooperation. The institutionconsists of the Department of Cardio-Vascular Surgery; the Department ofCardiac and Circulatory Diseases; theDepartment of Paediatric Cardiologyand Congenital Heart Disease as well asthe Institute for Laboratory Medicine;the Institute for Anaesthesiology andthe Institute for Radiology and NuclearMedicine.

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Welcome to the German Heart Centre Munich

The German Heart Centre Munich has gone down in history as aparagon for the consolidation of state of the art medical treatmentof cardiovascular diseases at one centralised location.

The German Heart Centre Munichstands for the highest standard ofmedical excellence worldwide. More-over, it has been a motivating force formany medical advancements. Since itsfoundation,more than 425,000 out-patients and over 142,000 in-patientshave been treated at the hospital. Morethan 32,000 open-heart surgical proce-dures have been performed. The firstsuccessful heart transplantation inGermany was performed here in 1981.

Today every type of open-heart surgeryis performed routinely. For aorto-cor-onary bypass surgery arterial anastomo-ses are used in 94% of the proceduresbecause of their superior durability.For cardiac valve surgery, particularemphasis is placed on reconstruction

of the valve rather than its replacement.However, if replacement is necessary,an implant from a wide range of pros-thetic valves is selected according toindividual needs and the age of thepatient. The in-house Homograft bankhas proved to be successful and muchexperience has been gained in thetreatment of particularly complicatedcases. Cardiovascular surgery employsthe most modern technical equipmentincluding intraoperative blood flowmeasurement, angiography and ultra-sound examinations. In addition, newminimally invasive methods are em-ployed.

The heart surgery robot "DaVinci" wasintroduced at the Heart Centre in fallof 1999. With this system only three tiny

remote-controlled probes are insertedinto the thorax. With sensors and spe-cial software the movements of the heartsurgeon are translated from a controlpanel and carried out in the chest.

Paediatric cardiac surgery is one of themost important specialties. The Ger-man Heart Centre is one of the leadinginstitutions in this field. All operativecorrections of congenital heart disease,including cardiac transplantations,can be carried out. More than one-thirdof the patients undergoing surgerywere children of whom the majoritywere under the age of one year. Anotherarea of expertise is the medical treat-ment of newborns with a body weightof less than 2000 grams.

Focal points of the Cardiology Depart-ment are cardiac catheterisation andinterventions in the coronary systemfor which intraluminal stenting hasbecome an integral part. The GermanHeart Centre is one of the world's lead-ing institutions in the application ofthis method. The department is parti-cularly well-known for its methods ofemergency treatment of acute myocar-dial infarction. Another area of speciali-sation is the diagnosis and treatmentof cardiac arrhythmias with the mostup-to-date equipment and methods.In this regard, invasive methods withthe use of specialised catheters playsan increasingly important role. In addi-

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tion to numerous electrophysiologicprocedures, routine measures includepacemaker and automatic cardioverter-defibrillator implantation.

Diagnostic and interventional proce-dures have assumed increasing import-ance in the field of paediatric cardio-logy and the treatment of congenitalcardiac defects. The treatment possi-bilities include valvuloplasty, dilatationof narrowed blood vessels and closureof short-circuit connections betweenlarge blood vessels or between theatria. With the launching of the secondcatheterisation unit in the new facility,electrophysiologic and intravascularultrasound procedures are also perfor-med. The Department of PaediatricCardiology together with the Munich

Fire Department operate an emergencymedical service for newborn babies.

The Heart Centre's research laboratoriesand the cooperation with the TechnicalUniversity of Munich, ensure the con-tinuous development of methods andinnovative, scientifically based medi-cine. In addition to facilities for animalexperiments, the Heart Centre has itsown laboratory for molecular biology.At the heart of the new complex, whichopened in October 1996, are five oper-ating theatres completely equippedfor cardiovascular surgery and six car-diac catheterisation units. Three inten-sive care units with a total of 42 bedsare equipped with state-of-the-arttechnology. With a fully digitalized X-ray technique, a pilot project was

implemented in the State of Bavaria.An image network (PACS) as well as adigital X-ray archive and a radiologicalinformation system was installed re-cently. At the Institute of LaboratoryMedicine all data is processed electro-nically via the hospital informationsystem and is immediately retrievableon the wards. The German Heart Centrealso has special facilities such as itsown pharmacy, helicopter landingport, social services, blood bank andphysiotherapy.

Support services for the relatives ofthe patients is also available. A housesponsored by the Ronald McDonaldChildren's Aid provides accommoda-tions for the parents of young patientson the grounds of the hospital complex.

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Humanity approach

The German Heart Centre combinesstate of art medical treatment with hu-manity. It is the flexible, highly moti-vated involvement and cooperation ofvarious professional groups workingas a team that enhances the recuper-ation and recovery of the patients. The physical, emotional, social andcultural needs of the patients as wellas their right to self-determination arefundamental to our work. Our goal isto provide diagnostic, therapeutic andother services tailored to the needs ofeach patient.

Responsibility

Above and beyond the specialisationof the various professional groups anddepartments, each member of theteam is devoted to combining highly-technological medicine with humanecare. Because of the substantial re-sponsibility assumed by the staffmembers, their needs are importantas well. They must be involved in thedecision-making process in their ownand/or related fields. Communicationtranscends professional hierarchies.To maintain the high standard ofmedicine at the Heart Centre, all staffmembers regularly take part in pro-fessional development programmes.

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Vision

The German Heart Centre Munichprovides state of the art medical carefor children and adults with cardio-vascular disorders.

Competence

Cardiovascular disease is the mostcommon cause of death in western industrialized nations. In Germanyabout 6,500 children are born annuallywith congenital heart defects. The Ger-man Heart Centre was one of the first"one-organ" institutions to successfullyprovide interdisciplinary treatment ofcardiovascular diseases. It was ourobjective to lower the number of deathscaused by cardiovascular disordersthrough preventive and highly specialised medicine. Clinical research at theHeart Centre as well as research in collaboration with the Technical Uni-versity of Munich solidify the centre'sleading position in the developmentof diagnostic and therapeutic conceptson a national and international level.

Loyalty

The professional and personal integri-ty of each staff member provides thebasis for responsible interaction withpatients, their relatives and colleaguesas well as the cooperation with practi-tioners and other health care professio-nals and institutions. All staff membersloyally support "enterprise" GermanHeart Centre Munich. We are aiming at optimal efficiencyand a conscientious environmentalcontext.

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The size of a clenched fist, the adultheart pumps up to 8.000 litres ofblood daily at a rate of 5 litres perminute. It can theoretically fill threebathtubs within an hour and fifty-fiveOlympic-sized swimming pools withinthe lifespan of a seventy-year-old. Theheart and blood are essentially inter-connected, they form a symbiotic re-lationship, a perpetual cycle working

day and night shifts that they can becalled, in modern business terms, ajoint venture which the heart regulatesand orchestrates. Thirty billion redblood cells race through the body over96,000 kilometres of arteries, veinsand capillaries, the body's express-ways, streets and alleys. The capil-laries are so narrow that the bloodcells can only pass through in singlefile. As the heart itself needs to besupplied with blood, coronary arteriesencircle it like a wreath.Every second the bone marrow produces

two million new red blood cells. Eachcontains hemoglobin which chemicallybinds with oxygen. At a rate of seventytimes a minute, the heart pumps theblood with its cargo of red blood cellsinto the lungs. There the red bloodcells are loaded with oxygen and em-bark on a journey longer than twicearound the world.

The heart is the first stop. The oxygenenriched red blood cells are pumpedfrom the left atrium to the left ventricle.Pacemaker cells activate the contraction

How the heart works

No mechanical device, no water faucet, hoseor pump is a true match for the human heart;it is the most efficient pump ever created.

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of the muscular walls of the heart. Theheart valves then open and red bloodcells are pumped into the blood vessels.Initially, they race through the body;near the heart the vessels are like ex-pressways. The ultimate goal of thered blood cells, however, is the eachindividual cell. Every single one mustbe supplied with oxygen and othernutrients that can be converted intoenergy. So their speed is reduced grad-ually and they are finally dispersed in-to even the narrowest of alleyways.After unloading their oxygen cargo,

the red blood cells flow back to theheart through the veins. They are su-cked into the right atrium of the heart.The right ventricle pumps the into thelungs and, once again, the red bloodcells are refuelled with oxygen beforethey flow to the left side of the heart.Their speed depends on the heartbeat.An athlete's heart can beat about twohundred times a minute, almost threetimes more quickly than the heart ofan untrained person. An untrainedheart pumps a good five litres perminute; the heart of an athlete pumps

twenty-five litres. The athlete's heartalso weighs more; the heart of a non-athlete weighs about three hundredgrams while that of an athlete canweigh almost twice as much.

In ancient Egypt being athletic couldhave led to eternal hell and damnation.The ancient Egyptians believed that incourse of a lifetime sins accumulatedin the heart. The heart was weighed onthe final judgement day – the heavierthe heart, the more sinful it had be.

However, it was not until the Englishanatomist William Harvey announcedhis discovery of the true nature of thecirculation of the blood in his "De Mo-tu Cordis et Sanguinis" (On the Move-ment of the Heart and Blood) publishedin 1628 that the background for moreunderstanding was established. Hecalculated that the heart pumped morethan twice the entire blood volume ofan adult in a half hour. As this volumecould never be exhausted and thennewly produced by the body, he con-cluded that there must be a finiteamount of blood in a closed system oftubes within the body. This was a purely scientific observation; there wasnot even a hint of the heart as the cham-ber of sins or the seat of the soul.

Harvey broke with tradition. 2.100years before his time, the poets of theSumerian Gilgamesch epic viewed theheart as the symbol for emotions. TheChinese attributed to the heart an ad-ditional centre of the intellect. Greekphilosophers separated formal andlogical cognitive ability from the heart

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and relegated it to the brain. Aristote-les proclaimed it the seat of the ever-lasting soul. In the Middle Ages theheart appeared as a symbol of Christianmysticism. Christian regarded theheart of Jesus as a symbol for God'slove for mankind.

"I think, therefore I am." contradictedthe philosopher and scientist RenéDescartes in the seventeenth century.Doubtful of the faculties with whichparts of the body were then thought tobe endowed, he considered feelings

in the heart region deceptive. Theseconclusions coupled with those ofWilliam Harvey changed the reflectiveconcept of the heart in the Age of En-lightenment. The heart was no longerthe seat of emotions, the soul or ofconscience, but rather a perfect hydrau-lic pump.

The emphasis on feelings and imagi-nation in arbitrary opposition to logicand reason during the Romantic periodled to a rejection of image of the heartas a pump. The heart now stood for all

things intangible, incomprehensibleand otherworldly. Language itselfbalked at the idea of the heart as anorganic pump; after all the heart canbe broken, one can cry one's heartout, lose one's heart, or wear one'sheart on one's sleeve. Even todaythese idioms are common usage.Scientists have stopped trying to fightpsychological explanations since theytoo are at a loss to explain preciselywhat induces this muscular pump todo what it does. How does a pacemakercell know it should contract seventy

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times a minute? What is the essenceof this mysterious force that only a fewcells possess? In strictly biologicalterms, the sinus node in the rightatrium generates electric impulsesand conducts them throughout themuscle of the heart, stimulating theheart to contract and pump blood.Although this happens independentlyof the brain and the spinal cord, it isinfluenced by the nervous system. Thesympathetic nervous system accele-rates the heart rate while the para-sympathetic nervous system, particu-

larly the vagus nerve, decreases it. Many people have felt their heart bea-ting in both pleasant and unpleasantsituations. The parasympathetic ner-vous system, together with the sympa-thetic nervous system, constitutes theautonomic nervous system, the branchof the nervous system that performsinvoluntary functions. The sympatheticnervous system causes sudden heartpalpitations by quickly releasing non-adrenalin at the nerve endings of theheart muscle. The vagus nerve willtemporarily accelerate the heart rate

as adrenalin is set free. The functionof the heart, therefore, is also influ-enced by emotions, fears, joy andmental health.

Theoretically at least, each red bloodcell can sense if a person is in an extraordinary psychological situation.The red blood cell has three monthsto recognise this situation and then itdies. However, the bone marrow cease-lessly produces new blood cells andthe heart continues beating. Inciden-tally, almost always on the left.

At the Clinic for Cardiovascular Surgerythe complete spectrum of cardiac sur-gery is performed, i.e. paediatric sur-gery, reconstruction and replacementof heart valves, bypass surgery, surgi-cal reconstruction of the intrathoracicaorta, heart transplantation and im-plantation of artificial hearts.

In the field of acquired heart defects, more and more procedures are performedin a minimally invasive fashion. For instance, the mitral valve is reconstructedthrough minimal incisions on the right side of the thorax. For surgery on the as-cending aorta, the sternum no longer has to be opened completely, but the ope-ration can be performed through a partial opening of the upper part of the ster-num (partial sternotomy). Thanks to state-of-the-art surgical techniques, defectiveheart valves can now be reconstructed instead of being replaced in an increa-sing number of cases.

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Department of Cardiovascular Surgery

The Clinic for Cardiovascular Surgeryat the German Heart Centre Munich isa specialised clinic for the treatmentof congenital and acquired cardiacdefects.

At the German Heart Centre Munich allvalve-preserving techniques are perfor-med, especially with regard to the mitralvalve. Furthermore, the clinic is equip-ped with a telemanipulator (robot) forspecial operations. The world's first totalendoscopic mitral valve reconstruction,a procedure which did not require ope-ning of the thorax, was performed atthe German Heart Centre Munich withsuch a telemanipulator in 2000. Certainprocedures on the coronary vessels canalso be performed in a total endoscopicfashion with the telemanipulator. Someoperations on the coronary vessels cannow be performed on the beating heartwithout the use of the heart-lung-ma-chine, which marks another major ad-vancement in cardiac surgery.

lung-machine. Minimally invasiveprocedures also play a more and moreimportant role in paediatric cardiacsurgery. The German Heart Centre hasits own valve bank, where human valvesare prepared for the replacement ofthe pulmonary valve, a frequent proce-dure in children with congenital heartdefects.

The Clinic for Cardiovascular Surgeryhas a large experimental laboratorywhere numerous research projects ta-ke place, e.g. the development of anautomatic heart-lung-machine, thebreeding of tissue cells (tissueengineering), the experimental andclinical examination of heart valves,the development of state-of-the-art

Various procedures are available atthe Clinic for Cardiovascular Surgery totreat defects of the intrathoracic aorta.Among other things, stents (internalvascular support devices) have beenimplanted for several years withoutopening the sternum and withoutusing the heart-lung-machine.

The Clinic for Cardiovascular Surgery isamong the world's leading institutionsin the treatment of congenital heartdefects in newborns, infants and chil-dren. Complex congenital heart defectscan even be corrected in very smallbabies with a birth weight of less than2000 grammes. This is possible bymeans of deep hypothermia of theorganism with the aid of the heart-

Contributions to cardiac surgery:

@ First successful heart transplantationin Germany

@ Introduction of anastomosis of the mammary artery in Germany

@ New methods of conserving hearttransplants

@ Establishment of a homograft bankfor the preparation of human valves

@ Use of biological valve prostheses@ Improvements in extracorporeal

circulation@ Quality assurance in cardiac surgery

(pilot project)@ Surgery with telemanipulators@ Development of a new centrifugal

pump

International leading position in thecorrection of complex congenital heart defects:

@ Anatomical correction of TGA (trans-position of the great arteries)

@ Fontan's operation@ Operation of BWG syndrome (Bland-

White-Garland syndrome)@ Vavuloplasty in patients with

Ebstein's anomaly@ Diaphragmatic pacemaker in patients

with Ondine's syndrome @ Double switch operation

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techniques for surgical robots as wellas the development of an artificialheart-replacement pump. In this field,scientists work hand in hand withphysicians, which guarantees an extra-ordinary degree of scientific efficiency.

Even as a student you were determi-ned to be a heart surgeon. Why?Surgery on the heart is more complexthan on motionless organs. But as astudent I did not know that a heartsurgeon is exposed to much morestress than any other surgeon.

Stress leads to heart attacks, at leastsome doctors say...Yes, OK. But I think that stress at workor stress induced by problems is not acause of heart disease. What is moreimportant is how the individual dealswith stress. My work is very rewarding,especially the graditude of the patients

after the operation. This is a chance totransform stress into energy.

Are there times when you regrethaving chosen this profession?No. Naturally, sometimes I would liketo go out to eat or for a walk in thepark. Just like that. There are too manydays on which I get up in the morningand go to the clinic when it is dark out-side and when I come home, it is darkagain. But then there are the momentsof thankfulness that I can help so manypeople.

Those who want to help must suffer?The little free time I do have, actuallyhas to be coordinated with my work. Iperform about 450 operations each

year, about two per day. On the daybefore an operation, I cannot do stre-nuous sports because I need 100% ofmy energy for the operation the nextday. I cannot eat too much either be-cause then I sleep restlessly.

How long does a heart operation take?For open-heart operations the hearthas to be stopped. This must not takelonger than three hours.

Can you interrupt such an operation?No.

With the need for such high concen-tration, do you sometimes havedoubts about yourself?No, if a race driver thinks he should

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Interview

Prof. Dr. Rüdiger Lange (M.D.)Director of the Department of Cardiovascular Surgery

drive more slowly, he is not very wellsuited for his job.

Dr. Brinkman from the Black ForestClinic (a long-running German televi-sion series) constantly had self doubts.Heart surgeons are subjected to muchmore pressure than the doctors on tele-vision. In the programme, the doctorsare mainly concerned with the personalproblems and the everyday life of theirpatients. If I were to do that, I would bein need of a psychiatrist in a few months.I get a stomach-ache when I watch thoseprogrammes. But I know some collea-gues who enjoy them.

Do you and your colleagues at leasthave enough time to deal with thepsychological state of the patients?Of course. Patients with a heart problem

are above all afraid when they come tosuch a highly specialised clinic. Thefirst thing we do is try to alleviate theirfear and create an atmosphere of trust.Not only a relationship of trust withthe nursing staff and the physicians,but also trust in the healing power ofmodern medicine, which is our mosteffective tool.

There are several heart centres inGermany. Is there competition forpatients?Yes, that is why additional specialisa-tion like here at the German HeartCentre is becoming more and moreimportant. The best possible care forand the wellbeing of our patients de-termine our thoughts and deeds. Thatis why many of our patients recom-mend our clinic to others.

Will genetic engineering and biotech-nology change heart surgery?Both fields will certainly cause majorchanges in surgery. In the years to comethere will be fewer operations becausewe will learn how to prevent diseases.

For many people the heart is not anormal organ but the site of the soul,emotions and feelings. What is theheart for you?The emotional component is based onhuman imagination, not reality. Still, asa physician I feel respect for the heart.It has a central position in the body.People feel that it is an organ that hasa life of its own. But of course that isnonsense. We only live because theheart supports the circulation.

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In industrial nations, more people dieof cardiac-circulatory diseases than ofall cancer diseases and accidents puttogether. Today, "Balloon dilatation" iscomplemented in most cases, by theimplantation of stents (vascular sup-ports made of fine metal network).

This applies particularly, to the newly developed drug-eluting stents with whichrestenosis can be completely prevented in most cases. Today, the technique ofballoon dilatation with the implantation of stents is also the best-possible thera-py, for reopening constricted infarction vessels for patients of acute cardiac in-farction. The long-term consequences of infarction can thus, be severely reduced

or completely eliminated. As opposedto the treatment of acute myocardialinfertion with thrombolytic agents only,catheter intervention clearly improvesthe long-term survival. The departmenthas the most experience in thesemethods of treatment worldwide.

100,000 Germans die of sudden heartfailure each year. One of the duties ofthe German Heart Centre is to detectthe inherent risk of dying through sud-den heart failure. The most modernmethods are available for diagnosis:Electro-physiological examinationswith controllable catheters allow for aprecise insight into the conditions ofblood conveyance in the heart duringheartbeat. Life-threatening arrhythmiacan be eliminated through the implan-tation of pacemakers with defibrillatorfunction. Patients with life-threateningdiseases are treated in intensive-careunits with new monitoring methodsand techniques of diagnosis, highly-developed respiratory and dialysisdevices, endoscopic techniques aswell as mechanical cardio-circulatorysupport systems.

Emergency patients can benefit fromthe services of the clinic round-the-clock in seven days of the week. Theclinic occupies a leading position world-wide in cardiac catheter operations inemergency cases.

In the field of science, the clinic com-bines cardio-vascular fundamentalresearch with clinical research.

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Department of Cardiac and Circulatory Diseases

One major responsibility of the German Heart Centre is to open up constricted coro- nary arteries without surgical intervention.

Contributions to adult cardiology

@ Improvement of interventional treatment of acute cardiac infarction@ Optimization of the concomittant medical treatment of acute coronary syndromes@ Problem of restenosis following balloon catheter dilatation and stent implantation@ Optimization of the technique of stent implantation and long-term results@ Development and testing of drug-eluting stents@ New therapy concepts in the application of platelet aggregation inhibitors, fundamental

research on the function of blood platelets and the physiology of coronary arteries@ Molecular cardiology: Identification and analysis of the vessel-constricting processes

and genetic pressure factors@ Quantitative coronary arteriography, intracoronary ultrasound examination and the

Doppler velocity measurement@ Regional myocardial blood flow in case of the coronary heart disease pharmaco-therapy

of coronary heart disease @ Regional myocardial blood flow in case of the coronary heart disease @ Pharmaco-therapy of coronary heart disease@ Nitrate tolerance - Concepts of avoiding tolerance@ Quantification and the catheter-supported therapy of diseases associated with cardiac

hypertrophy ("hypertrophy obstructive cardiomyopathy")@ Quantification of stenotic valvular diseases and valvular regurgitations by means of

the Doppler and colored Doppler-Echocardiography as well as trans-esophageal echocardiography

@ Criteria for the optimal period of surgery in case of cardiac valve dysfunction@ Long-term examinations after the substitution of cardiac valve and balloon catheter

vavloplasty@ Pharmacotherapy and drug interactions in case of cardiac insufficiency@ Irregularity of pulse: Complex systems of pacemaker, implantable cardiovert-defibrilla

tors, highly amplified ACG, catheter ablation, deflection of monophasic action potentials

In years past it was said that cardio-logists are only responsible formaking the diagnosis. Someone elsedid the treating and operating…This is no longer the case. Most of ourpatients are diagnosed and treatedright here in our department. In themeantime less than 10% of our pa-tients require surgery. We treat most ofthe patients ourselves on a long-termbasis.

One of your instruments is a balloon.What do you do with it?This balloon is inserted with a catheterinto a diseased coronary artery. Up tothe point where the vessel is constric-ted. The balloon is then inflated andthe constriction dilated so that the

blood flow can be restored. This proce-dure is called balloon dilatation.

And it helps for severe constriction?Yes, often. In case the ballon dillationis not successful, we insert a fine metaltube into the vessel to provide stabilityand to avoid renewed constriction.The tube is called stent. Balloon dila-tation and stent implantation are twoof the most significant developmentsin our field over the past years. Theyhave fundamentally changed the treat-ment of patients with coronary disea-ses and will also do so in the future.

Could you explain this further?In the last few years it has been shownthat drug-eluting stents are associatedwith a substantially lower rate of res-tenosis. This means that a patient rare-ly needs a bypass operation currently.

This type of stent is increasingly repla-cing the uncoated stents and is, there-fore, one of the most important inno-vations.

In spite of the advances, heart disea-se continues to be the number onecause of death in the industrializednations.Correct, heart disease is responsiblefor many more deaths than all forms ofcancer combined. This in spite of out-standing advances in our field – as op-posed to treatment of cancer in whichthe colleagues are still waiting for abreak-through. However, I am optimisticthat cardic death will no longer be infirst place in ten years time.

It is said that the technical facilitiesfor treatment of acute myocardial infarction are already optimal?

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Prof. Dr. Albert SchömigDirector of the Department of Heart and Circulatory Diseases

Interview

That may be, but they are not beingused or not being used early enough.The truth is that most patients have towait too long for the right treatment orthey are initially admitted to a hospitalwhere targeted treatment is not avai-lable.

You are the initiator of the "MunichInfarction Model" intended to gua-rantee the best possible treatmentfor patients with acute myocardialinfarction. What changes should thisspecifically bring about?Our goal is that patients be admitteddirectly in the appropriate hospital.Without loss of time, we can ensurethat all patients in the Munich areawill be treated immediately at a quali-fied heart centre. The infrastructure isthere, however it is not being used.

How many heart attack patients' lives could be saved?Of those admitted to a hospital withan acute infarction, twice as manylives could be saved. If the "Munich Infarction Model" were implementedconsistently, there would be about500 fewer deaths from myocardial in-farction in the city each year.

If you treat heart attacks every day –are you afraid that you will have aheart attack yourself?No. I follow the Mediterranean dietwhich is low in cholesterol. Anyone whohas been on vacation in the Mediterra-nean area knows how good it tastes. Ialso recommend a glass of red wine inthe evening. Prevention does not onlymean limitation. Additionally, oneshould spend an hour jogging, riding a

bike, swimming two or three times aweek: simple things can lower the risk.

For decades doctors have been war-ning people about smoking but thenumber of smokers remains the same. Is that frustrating?Yes. This demonstrates that there arenot many possibilities to change be-haviour.

Did you ever smoke?Yes. When I was a student, I tried it afew times. But I noticed rather quicklythat this was not for me. Luckily, I didnot become addicted.

Many people are anxious about a treatment using catheterisation.It is normal to be anxious. Dealingwith the heart always entails dealingwith emotions. Talking with the pa-tients is very important. The patientshould have the feeling of being invol-ved in the treatment; He should betreated as a human being, not as anobject. We play music in the catheterlaboratory during the procedure and Iam sure that helps the patient to relax.Music also helps me relax.

Do you determine which musicshould be played?It must be relaxing. Otherwise, we canfulfil almost any musical request.

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The Department of Paediatric Cardio-logy and Congenital Heart Disease ca-res for patients with congenital heart defects from fetus to the adultand is one of the most active centresin Europe. Head of the Department isProf. Dr. John Hess, who is Medical Director of the hospital and Chair-man of the Hospital Board as well.

State of the art diagnosis and treatmentare offered to 8.000 patients (6.000outpatients and 2.000 inpatients) every

year. More than 600 cardiac catheteri-zatios in two digital biplane catheteri-zation laboratories are done every year,40 % of which are therapeutic inter-ventions like balloon dilatation and/orstent implantation of stenotic valves(aortic and pulmonic), vessels (pulmo-nay arteries, coarctation of the des-cending aorta), closure of atrial septaland ventricular septal defects as wellas persisting ductus arteriosus.

"Simple" congenital leasons like ven-tricular septal defects, atrial septaldefects not suitable for intervention,atrioventricular septal defects and hy-poplastic left heart syndroms are dia-gnosed by echo only and surgically ma-naged the surgeons without diagnostic

catheterization. Transesophagealechocardiography in complex lesionspre- and intraoperatively is one of thetopics in the echolab. 9000 transthora-cic and 500 transesophageal examina-tions were done in 2002.

550 patients - more than 200 youngerthan one year - are operated on everyyear. All preoperative diagnosis is donein the Department of Paediatric cardio-logy and Congenital Heart disease inclu-ding ultrafast computer tomographyand magnetic resonance imaging if ne-cessary. Immediately after the opera-tion patients are treated in the intensivcare unit of the paediatric department -with fully equipped 16 beds the largestone in Germany.

Department of Paediatric Cardiology and Congenital Heart Disease

When the German Heart Centre Munich wasfounded in 1974 the idea of diagnosing and treating any illness of the heart in any age wasunique in the world and was copied by manyhospitals in several countries afterwards.

Specific achievements of the department

@ Interventional cardiac catherization (repair)Balloon dilation of aorta and pulmonaryvalves, angioplasty and "stenting" of pul-monary artery stenosis and descending aorta, catheter device closure of the atrial septal (ASD) and ventricular septal defects(VSD), closure of aortopulmonary collateral vessels, coronary artery fistula and patentductus arteriosus (PDA)

@ EchocardiographyFetal echocardiography (with 3-D recostruc-tion), transthoracic and transesophageal echocardiography (TTE)

@ ElectrophysiologyMapping of all primary and secondary atrial arrhythmia with the CARTO system, ablationof atrial and ventricular tachycardia in heartswith complex cardiac defects, for instance after Fontan operations or after transpositionof the great arteries (TGA)

@ Paediatric Cardiac SurgeryEvery type of reconstructive and palliative cardiac surgery, including the Norwood palliation, staged univentricular heart palli-ation, correction of anomalous left coronaryartery from the pulmonary artery (ALCPA), Fallot' tetralogy in neonates or infants lessthan one year of age, AV septial defects, reconstructive surgery of Ebstein's abnomalyas well as the Ross operation (also neonatal)

Specific tasks of the German Heart Centre asa university clinic:

@ educational courses for medical students@ basic research in the molecuar biological

laboratory@ clinical long term follow up studies after

specific treatment of congenital heart disease,studies on myocardial performance and myocardial perfusion

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As children are not just little adults awarm and familial nursing atmosphereis provided on the two standard wards.21 beds are reserved for neonates, in-fants and school children - 4 roomsare spezially equipped for mother andbaby nursing. On the other ward 11beds are presented for older childrenas well as adults in 5 single (hotelstandard) and two three bed rooms. In both wards, specially trained nursescare for mothers, fathers and theirchildren. All beds are fully equippedwith ECG monitor, including 0-2 satu-ration and can be supervised centrally.

Psychosocial support is provided byone spezialised nurse and two psycho-logists who care not only for the pa-tients but also for the parents in theirdifficult situation before or after theoperation. A teacher helps school chil-dren individually so that educationcan be continued in case of a longerhospital stay. In the hospital area thereare two appartment houses with 27appartments for parents and otherfamily members located.

The Department of Paediatric Cardio-logy and Congenital Heart Disease is

located on the third floor with allthree wards (48 beds in total), twocath labs and two echolabs. The out-patient department as well as the ad-ministration are situated on theground floor.

A 24 hours service for acute help isprovided all over the year - emergen-cy catheterizations or cardiac surgerycan be done at any time. The medicalstaff consists of 39 medical doctors,of whom eleven are senior staffmember, 14 junior staff member, butall fully trained specialists and 14interns and fellows in training.

As part of the Technical University ofMunich there are widespread researchactivities: Basic research in the fieldof pulmonary hypertension and itsmolecular regulation, acute inflamma-tory disease in chidren after bypassoperation and capillary leak syndro-me, departmental research with spe-cial interest in myocardial perfusionand cellular metabolism in congenitalheartdisease, haemodynamic andmorphologic correlation in univentri-cular hearts, and specific cardiovas-cular monitoring on the ICU.

Is it different to treat children?Oh, yes. It is very important to gainthe child's trust, otherwise the treat-ment has little chance of being suc-cessful. Adults cooperate becausethey know that it is necessary for theirhealth. Children only cooperate if theytrust the doctor.

Are children better patients?For me, children are the more interes-ting patients because they are morehonest than adults. If an adult doesnot like a doctor or a nurse, usually heor she will not say anything. Childrendo not try to fool you, they do not lieand they are more reliable.

How do you win the trust of children?I am also honest. If a child gets an in-jection, one frequently hears the pa-rents say "that does not hurt, you donot have to cry." But naturally it doeshurt. If one notices that a child isafraid of the injection, one shouldshow that one knows it and try to alle-viate some of the fear with a good ar-gument. You cannot demand the childto be stronger than it is.

May there be psychological damage ifa child spends a long time in hospital?Yes, that may be possible. We needmore psychologists and specialisedteachers to care for these children. Thegovernment and the insurance compa-nies do not provide us with sufficientfunds for these needs. Still, we have

hired two psychologists and two speci-alised teachers.

Sometimes clowns hop around thewards…Yes, those are our hospital clowns, re-al clowns, that come once a week tocheer up the children. When the chil-dren laugh, they forget that they aresick. But we also have toys and evencomputers for the older children.

Do parents also provide support fortheir children?Essentially, yes. But one aspect is fre-quently overlooked; if a three-year-oldchild repeatedly has to suffer and themother is present, the child may feelsomehow abandoned and think thathis mother is not protecting him.

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Interview

Prof. Dr. John HessDirector of the Department of Paediatric Cardiology and Congenital Heart Disease

Naturally, the parents should be the-re, but it can be counterproductive.

The heart of a newborn is about asbig as a walnut. Is it possible to workprecisely with such a small organ?Yes, that is difficult, especially cardiaccatheterisation. Without being able tosee anything in the groin, one has topuncture two little vessels that arethinner than a matchstick. The cathe-ters are passed through the vein andartery to the heart. One has to be verycareful and watch out for resistance.Of course, this can be learned, butone should have some talent.

You have three children yourself.What goes through the mind of pa-rents on learning that their child has

a heart defect?They experience a shock. In this situa-tion, most parents do not understandthe medical aspects of what we try to ex-plain. You have to give them time to getover the initial shock. Our doctors regu-larly take part in communication cour-ses where I play the part of a motheror father of a child with a heart defect.

What are the causes of congenitalcardiac defects?We know very little. The heart deve-lops between the fourth and seventhweek of pregnancy. If the mother has aviral infection such as measles duringthis time, a heart defect can occur. Asecond cause is a genetic defect. Still,we only know the cause in about 25%of the cases. We are working on it.

What goes through your mind whenyou cannot help a child?The worst case is when a child dies ofa viral infection of the heart muscle,not a congenital defect; a completelyhealthy child suddenly dies. This is acatastrophic event, not only for the pa-rents but for me as well. But thankGod, such diseases are rare.

The death rate in the Department forPaediatric Cardiology is less thanthree percent……this is unique in Germany. There areonly five departments in the worldwith such a low rate. But more inter-esting to me is that later the childrencan lead normal lives. I want to dis-charge healthy children with a long life expectancy.

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The physicians of the Institute forAnesthesiology treat and monitor allpatients that have to undergo heart-surgical operations in the operatingroom and in the intensive-care unit.

One notable challenge in the process is also to safely guide elderly patientswith a long process of illness or in a strongly impaired general departmental con-dition through the perioperative phase . Since 30 years, staffs of the departmenthave been meeting the complex standards in cooperation with the affiliatedblood-group-serological laboratory and blood bank, its unit for pre-surgical auto-loguous blood donation as well as physiotherapists belonging to the institute.

Given the system of autologuous blood donation which was introduced in1989, the probability of using blood transfusion stemming from third partiesin operations could be drastically reduced. The blood components donatedapproximately 6 weeks ahead of the surgery are mostly stored separately andmade available for the operation.

After a detailed preliminary discus-sion with the patient in the ward, oneday before the operation, all patientsare given a tranquilizer for the nightand a strong "pre-anesthetic medica-tion" on the day of surgery ahead ofremoval to the operation room asprescribed by the anesthetist so thatthey are already very sleepy when theactual anesthesia is introduced inthe vestibule of the operation room.

During surgery, the patients are sur-veyed at the highest safety level withthe most modern hemodynamic inter-linked monitoring system, and com-puter-controlled data management.

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Institute for Anesthesiology

Prof. Dr. Peter Tassani-PrellDirector of the Institute

Highly specialized cardio-anesthetists ren-der the whole spectrum of cardiac surgeryas it is routinely practiced at the GermanHeart Centre Munich.

Milestone contributions to anesthesia

@ Development and optimization ofthe pre-operative supply of patientsduring and after cardio-surgical interventions

@ Introduction and further developmentof methods of intravenous anesthesiawith ultra short acting anestheticand analgetic agents in the sense ofa total intravenous anesthesia

@ Directive departmental examinationsfor recording the impacts of extra-corporeal circulation on the clotting system

@ Examinations for the pharmacologicaltreatment of the malfunction ofblood clotting during and after ope-rations with the aid of extra-corporealcirculation

@ Introduction of mechanical blood-sa-ving measures after heart operations

@ Build-up of the system of autologuousblood donation

@ Working out the theoretical and tech-nical prerequisites for the performanceof hypothermal circulatory arrest forthe correction of cardiac diseases

@ Introduction of new techniques forthe pharmacological and mechanicalimpacting of systemic inflammatoryresponse during and after extra-cor-poreal circulation

@ Introduction of the pre-operative, continuous computer-backed recor-ding of the vital parameters of pa-tients for documentation and qualityassurance

The maintenance of sufficient circulatory conditions during cardiac surgery par-ticularly after the deactivation of the heart-lung-machine, is mostly possible onlyby the use of sophisticated medication to increase the contraction force of theheart, or to regulate the diameter of the blood vessels.

Trans-esophageal echocardiography, fiber-optical bronchoscopy, transcranialDoppler-monitoring of the cerebral blood circulation and the spectral analyticalevaluation of the EEG complement the possibilities of monitoring and controllingall vital functions during anesthesia.

One focal point of the department lies in the pre-surgical care and medical sup-ply for children and babies. Far more than 11,000 children and new-born babieshave been treated from 1974 to 2004. Since the middle of the 1970's, the techni-que of "hypothermal circulatory arrest", i.e. temporary circulatory arrest in caseof extreme hypothermia of the organism enabled the primary surgical correctionof complex in-born cardiac dysfunction in paediatric age. Today, decisive advance-ments in the field of heart surgery, extra-corporeal circulation as well as anesthe-siological management render the performance of almost all kinds of operationpossible even in new-born babies and premature deliveries of up to <2000 gramsbody weight while the heart-lung-machine is running.

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Laboratory medicine is indispensable in the diagnosis, prognostic assessmentand monitoring of an illness as well as the identification of cardiac risk factors.The Institute generally works behind the scenes and is often not apparent to thepatient. Laboratory physicians advise doctors, nursing staff and patients in allmatters of this rapidly advancing interdisciplinary field.

Several hundred analytical procedures for characterising naturally occurringsubstances, cells as well as drugs are constantly being updated and maintainedat the state-of-the-art. Presently about one million individual assays in the area

of hematology, hemostasis, general departmental chemistry, immunological and protein chemistry, serology, endocrinology, metabolism, gene testing and drug monitoring are carried out each year exclu-sively by specialists. All laboratory results pass through a multi-step technical and medical review pro-cess before the findings are made available to the physicians at the ward. The measurements obtainedare put through rigorous verification and continuous internal and external quality control measures toensure their accuracy. The findings are then validated through a patient-oriented medical assessmentcarried out by the doctors at the Institute.

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Institute for Laboratory medicine

Prof. Dr. Wolfgang VogtDirector of the Institute

"Only good is not quick enough" isthe guiding motto of the Institute forLaboratory Medicine. With 40% inten-sive care patients, the ability to offerhigh-efficiency in tandem with thehighest analytical quality is crucial.

The modern facilities are supported by an efficient laboratory IT system that isfully integrated throughout the entire hospital information system.

The Institute has operated according to the Total Quality Management guide-lines for the last ten years and was the first organisation of its type to be exter-nally assessed according to the model of the European Foundation for QualityManagement (EFQM).

Pathobiochemistry and the improvement of diagnostic techniques for heartdisease remain at the forefront of research at the Institute. However, it alsofosters the research of all other departments with its analytical skills.

The Institute is a leading centre for educating patients on self-management oforal anticoagulants. (Contact person: Dr. S. L. Braun)

Contributions to Laboratory Medicine

@ Development of laboratory techni-ques and methods for the prophyla-xis, diagnosis, therapeutic monito-ring and monitoring of the course ofheart diseases.

@ Competence centre for laboratorymedicine

@ High-efficiency analysis@ Frequent and detailed advisory service@ Patient training@ Optimisation of economic efficiency

by means of business administrativemethods and of application of Total Quality Management (TQM)

Scientific contributions

@ Studies conducted to investigate the pharmacokinetics of the ultra trace element vanadium and itstissue concentration in heart disease

@ Changes in serum concentration ofcardiac troponins relating to heartand muscle disorders

@ Studies conducted to investigate the changes in blood coagulation and inflammation reaction during and after heart surgery

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All examinations are digitally archived.The individual sections are cross-lin-ked with each other as well as withnumerous function wards and beddedwards for patients through a picturenetwork.

Radiological diagnostics offers all tech-niques that are of relevance to theestablishment. All types of vascularpresentations as well as interventionaloperations with catheter (also on thecervical arteries) form a part of theservices rendered by the institute.Children are examined with the lowestdosage values (e.g. pulsed fluoroscopy).Since spring of 2002, the worldwidefirst cardiac 16-slice CT is run in the In-stitute in cooperation with the depart-ment of adult cardiology. The mostoutstanding examination in this case,is the non-invasive coronary angiogra-phy. In this respect, the department is

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Institute for Radiology und Nuclear Medicine

Dr. Stefan MartinoffDirector of the Institute

The institute which was fully digitalized andfitted with ultra-modern equipment in 1996as the first of its kind in Bavaria, suppliesthe cardiac centre in the field of radiologicaldiagnostics as well as in the entire field ofnuclear medicine.

a prominent reference address formanufacturing companies worldwide. The institute has an extensive radiolo-gical information system and a so-called PACS-system (Picture Archivingand Communication System). Bothsystems contain pictorial and diag-nostic data of patients.

Like the department of RadiologicalDiagnostics, the department of Nuc-lear Medicine works round-the-clock.In addition to the special nuclear-car-diological techniques, the instituteoffers the complete spectrum of nuclearmedicine. Since the start of the year

2001, a digital dual-head camera ofthe most modern design is also inoperation here. The focal points ofdiagnosis are the scintigraphic fielddiagnostics in case of suspected acutecardiac infarction and examinations ofin-born cardiac dysfunctions. Seriouslyill patients of cardiac infarction areexamined with an additional gamma-camera at the cardiological intensivecare unit. Since May 1998, the institutecooperates in the field of researchwith the Director of the Departmentfor Nuclear Medicine (Prof. Dr. M.Schwaiger (M.D.)) of the TechnicalUniversity of Munich.

Contributions to Radiological and Nuclear-Medical Diagnostics@ Co-introduction of the digital subtraction angiography in venous and arterial

vascular diagnostics@ Introduction and optimization of myocardial scintigraphy in planar – as well

as in SPECT-technology@ Optimization of non-invasive nuclear-medical diagnostics of complex paedia

tric cardiac dysfunctions@ Co-introduction and optimization of the digital x-ray technique as well as

introduction of picture archiving and distribution techniques@ Introduction of non-invasive coronary angiography by means of the 16-line

multi-slice CT into the diagnostic routine.

Scientific contributions@ Participation in the scientific evaluation of interventional and operative therapy

concepts in myocardial revascularization particularly with nuclear-medical methods.

@ Participation in the scientific evaluation and further development of the inter-ventional treatment of carotid stenoses by means of stent implantation in cooperation with the departments of angiology and neurology of the Technical University of Munich.

@ Performance of studies in the field of cardiac image transmission (atrial morphology/ coronary disease) on the 16-slice CT

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The German Heart Centre has a staff of over 400 nurses as well as volunteersand nursing students from the Bavarian Red Cross and "Maria Regina" schoolof nursing. These nurses, students and auxillary staff are responsible for thephysical and emotional wellbeing of the patients.

The nursing staff is the largest of the professional groups at the German HeartCentre and it is in constant communication with the physicians and other me-dical staff. Patient care is also based on the best possible relationship bet-ween the nursing staff and the patient.

The high quality of patient care at the German Heart Centre can also be attributed to the excellentworking conditions offered by this modern and state-of-the-art clinic. Tasks not within the sphere ofpatient care such as providing the Heart Centre with drugs and medical supplies or waste disposal

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Patient Care

Burkhard KöppenDirector of Nursing Care

A qualified and motivated nursingstaff is necessary for the successfultreatment and care of patients. Theseprofessionals are primarily motivatedby a deep Christian need to care andlook after patients.

are relegated to ancillary personnel. Consequently, the 400 members of thenursing staff can attend exclusively to their specific duties.

Patient care at the Heart Centre is marked by individual planning according tostandard guidelines. Qualified and experienced professionals are on dutyaround the clock in three shifts.Each ward has a head nurse whom the patients can contact if they have specialrequests and questions. Continuity between the shifts is assured by direct interaction and a briefing onthe particular care of each individual patient.

The goal of the nursing staff is to provide committed and medically supportedpatient care for the wellbeing of each individual.

The members of the nursing staff ofthe German Heart Centre are respon-sibles for:

@ Three cardiac medical and surgical adult wards

@ Two intermediate care wards foradults

@ Two intensive care units for adults@ Emergency admissions unit for

adults@ Two cardiac wards for children@ Intensive care unit for children

(divided by age)@ Central operating rooms with central

sterilisation facilities@ Anaesthesiology department@ Four cardiac catheter units for

intervention therapy for adults and children

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Since 1999 surgical procedures at theGerman Heart Centre Munich havebeen performed with the "Da Vinci" robot. Since then the robot has conti-nually been refined and has becomean integral part of heart surgery at theinstitution. Previously the surgeonoperated directly on the patient withscalpel and suture; to get to the heart,the thorax had to be opened. With thenew robot, a "telemanipulator", theexternal thorax remains almost intact.

Totally endoscopic bypass operationsare new in heart surgery; three probesare inserted through centimetre-smallincisions into the chest. Two are usedto operate, the third contains a high-resolution 3-D camera system. On amonitor in the operating room the as-sistants can also constantly observethe operation. As opposed to humans,the new machine never trembles.

As opposed to offline robots, whichare programmed to lathe out thigh bo-nes for hip replacements, the onlinesystems are always under guidance of

the surgeon: the telemanipulator isnot deployed by a program, but ratheroperated by a human. The tiny instru-ment moves in the thorax guided byits remote control system. This becomespossible with the aid of additional jointswith six degrees of freedom (conventio-nal endoscopes have four: transverse,horizontal, sagittal, rotational).

The movements are transmittedthrough sensors and special softwaredirectly and instantaneously from thehands of the surgeon on the steeringconsole. Considerable training is re-quired, however, as the surgeon hasno direct sense of touch. For this pur-pose, selected surgeons from the Ger-man Heart Centre trained at MountainView, California, where the DaVinciwas developed. Among other things,they learned how to see instead of feelresistance while cutting. A force feed-back circuit, which could alleviate thisproblem, is under development.

The use of the robot renders possiblethe complete spatial separation of pa-

tient and surgeon. Specialists couldeven perform the operation at anotherhospital, provided that the data trans-mission is ensured.

Further advantages become evidentduring the training of students. Withcoupled devices, students can feel themovements of the surgeon's hands.With properly adjusted instruments,other types of surgery are feasible.Even surgery on the beating heart wouldbe possible with automated endos-copes. For this purpose, the surgeonwould carry out his manipulations ona "virtually" non-beating heart, whilethe motion of the heart can be correctedby the computer corresponding to theactual position of the tissue.

The device was developed by the Cali-fornia enterprise "Intuitive Surgical" inMountain View, Silicon Valley. The ori-ginal concept was developed by theUnited States Army. The goal was tokeep the surgeons behind the frontlines and still enable them to providesurgical treatment for wounded soldiers.

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Computer-aided surgery at The German Heart Centre Munich

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Since summer of 2002, the GermanHeart Centre has been operating the16- slice Cardiac CT which at that time,was first of its kind worldwide and wasspecially designed for ultrafast heartexamination.

In addition to the entire range of high-resolution Computed Tomography ingeneral and the non-invasive vasculardiagnostics of the complete body, thesystem also enhances a non-invasivepresentation of the coronary arteriesfor suitable patients.

This diagnostics requires only relative-ly little time and is quite comfortablefor the patient. It furnishes breath-taking three-dimensional reconstruc-tion of the heart and its coronaryanatomy.

Given this possibility of fast and non-invasive image transmission of the he-art, the system was selected also inthe year 2002 as one of the finalists ofthe German Future prize of the GermanPresident.

The Multi-slice Cardiac-CT is run in closecooperation with the Department ofAdult Cardiology, Prof. Dr. Schömig(M.D.) and the Institute for Radiologyand Nuclear Medicine, Dr. Martinoff(M.D.).

Ultra fast-Cardiac-CT

As of January 1, 2002, the responsibility for the management of the German HeartCentre was transferred to us by the Free State of Bavaria.

SANA KLINIKEN manages six highly specialized cardiac centres for babies, childrenand adults in Germany. The headquarters of the company is in Munich/Bavaria.As a private association of hospitals, SANA has united 60-odd hospitals into ahealth centre association. The successful management of these hospitals isthereby enhanced and the needs of patients and clients are met more fully. Thequality standard of SANA is benchmarked solely by the best in this sphere andseeks to afford satisfaction to patients, clients and staff.

SANA is a subsidiary company of the leading private health insurance providers inGermany that strives to be an exemplar to others by proving that top-level per-formance in the sphere of medicine and nursing is compatible with economicbusiness management.

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Sana Kliniken-GmbH – Private Management

Robert SiegertCEO

Progress

The most important service provi-sions are diagnostics, therapy,nursing and hospital management.SANA constantly does everythingin its power to provide these ser-vices in an economically viable,state-of-the-art, manner to ensurethe interests of the patients.

Motivation

We believe that only motivatedstaff is able to provide excellentsolutions. Therefore SANA promo-tes further training and delegatesas much responsibility and deci-sion competence as possible toeach employee.

Transfer of know-how

The SANA association promotesan exchange of know-how andexperience on the basis of mutualconfidence. Counselling and in-formation exchange make successrepeatable and help to avoid er-rors. Open communication enhan-ces transparency of know-how.

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Sana Mission and Vision

The German Heart Centre has a tradition ofexcellence. Since 1974 outstanding medicalquality has been the overriding goal of thehospital management. As internationallyrecognised specialists, they motivate theirco-workers to attend to critically ill patientsat a first-rate, state-of-the-art institution.Each and every one is committed to the re-

duction of the death rate of cardiovascular disorders. Quality control has beenan integral part of the medical and nursing profession for the last thirty years.

Nevertheless, medical and technological advances, the complex organisationof a hospital at which a successful medical outcome is the result of manyinterconnected steps, and increasing economic pressure in the field of healthcare call for even more effort: the key concept is quality management. As opposed to many other countries, quality control and certified medical qua-

lity were not required by law in Ger-many for a long time. Often taking theinitiative, the German Heart Centre'sproactive introduction of systematicquality control and extensive qualitymanagement was pioneering.

The German Heart Centre and four ot-her clinics were at the forefront inthe development of quality manage-ment for cardiovascular surgery. In1986 the German Society of Cardio-vascular Surgery set up a commissionto develop quality control; the Ger-man Heart Centre was a member fromthe very beginning. The pilot study

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Total Quality Management (TQM) – a puzzle with nine pieces

At the time of its founding in 1974,the German Heart Centre Munich wasthe first heart centre in Germany;since then many more heart centreshave followed its benchmark example.

1Leadership

4Partnershipsand resources

7People results

8Societyresults

9Key performance results

5Processes

6Customerresults

2Policy and strategy

3People

QUADRA was sponsored by the Ger-man Ministry for Research and Tech-nology as well as the Federal Ministryof Health and Social Security. Todayall clinics for cardiovascular surgeryin Germany participate. In the mid-nineties, the German Heart Centrewas among the first to take part inthe project for quality control in pae-diatric cardiology.

The German Heart Centre has opera-ted according to the Total Quality Ma-nagement (TQM) guidelines since1997 and was the first hospital of itstype to be internally assessed accor-ding to the model of the EuropeanFoundation for Quality Management(EFQM). This model, originally used inthe industrial sector, has become wi-dely accepted in the field of healthcare.

In 1999 the German Heart Centrecompeted for the Ludwig-Erhard Pri-ze, the German award for outstan-ding quality, which requires extensi-ve involvement with the principles ofquality management. The German He-art Centre was honoured as an exem-plary organisation and paragon for allhealth care facilities.

Quality management, Total Quality Management (TQM) and the European Foun-dation for Quality Management Excellence Model (EFQM-Model) are concretetools that continually challenge us to excellence. It is a puzzle with nine pieces.

1 Leadership. We self critically assess our management style. A patriarchal system no longer meet the requirements of a modern heart centre.

2 Policy and strategy. We realize that there are heart centres other than ours. We do not fear transparency or competition and are at all times willing to have the quality of our work independently assessed.

3 People. Keeping abreast with state-of-the-art developments and advance-ments is imperative at a high-tech medical institution. Professional develop-ment and close collaboration with other departments is therefore crucial.

4 Partnerships and resources. National and international cooperation in research, health care as well as management is maintained and encouraged. We share information and learn from others.

5 Processes. Diagnosis and treatment is more than the sum of its individual steps. The improvement of this process is a constant obligation.

6 Customer results. Over and beyond successful medical results, we take into account of the personal opinion of our patients and the referring physiciansas well as self help groups and organisations.

7 People results. The satisfaction of our patients is dependent on the satis-faction of our employees. Although not only because of this, we try to provide optimal working conditions.

8 Society results. Our mission, the state-of-the-art medical treatment and care of patients with cardiovascular disorders, is one we always have accomplishedsuccessfully. We are interested that the general public also be made aware of this.

9 Key performance results. For more than 30 years excellent medical and scientific results are a matter of course for us. We will and must continue to provide such results in accordance to our guidelines for thrift and eco-nomising requirements.

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40

One of the main aspects of their workis to build and maintain accommoda-tions for parents and siblings in theimmediate vicinity of specialised de-partments so that the family can bewith their child during treatment.

At the Ronald McDonald House directlynext to the German Heart Centre – thesixth Ronald McDonald House in Ger-many – nine comfortable apartmentsas well as common rooms such as akitchen, laundry room, play area, re-creation room and TV room are avai-lable. The house manager lives on site.Her as well as a number of volunteersare available to help and support thefamilies at all times.

The total costs of the House were aboutone million Euros and were completlyfinanced by donations, most of whichcame from McDonald's franchisees.There were also many donors andsponsors from industry and commer-ce. Additionally, many private indivi-duals familiar with the McDonald'sKinderhilfe, support the house withgenerous donations which are beingused to maintain the existing housesand help to build new facilities.

As the Ronald McDonald's House wasnot able to meet the demands of allthose who needing accommodations,the German Heart Centre provided thefoundation with another 1.000 square

meters in the old department building– sufficient space for 18 more apart-ments – bringing the total to 27. The new Ronald McDonald House wasopened up in September 2000 by theformer Bavarian Minister of Science,Research and Art, Dr. Hans Zehetmair.

Ronald McDonald HouseGerman Heart Centre MunichLothstr. 1180335 MunichGermany

Telephone: +49 (0) 89 189507-0Fax : +49 (0) 89 189507-13

McDonald’s Kinderhilfe

The goal of the McDonald's Kinderhilfeis to help critically ill children andtheir families.

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In the prevailing times of limited finan-cial resources and in spite of fees forservices as well as state and federalassistance, the Heart Centre is depen-dent on this financial support. Since itsestablishment, the Foundation hasprovided over 2.5 million Euro for theacquisition of new equipment, organi-sation of medical congresses, distribu-tion of scientific publications, surgeryat no cost for those unable to afford it,and accommodations for family mem-bers of hospitalised patients.

In collaboration with the departmentaldirectors and management, the Boardof Directors decide on the most meaning-ful and cost-effective use of the funds

adhering to strict scientific and ecolo-gical considerations.The main body of the Foundation con-sists of a seven member executive board, who are responsible for the annual budget, the annual report andthe recruitment of new members.Along with the commitee they also promote the goals of the Foundation.

Why should I become a member of theFriends of the German Heart CentreFoundation?Cardiovascular disease in the industri-alized nations is still the number onecause of illness and death.One of every two individuals in Germanywill at one time or another develop so-

me type of cardiovascular disorder.This means that you, a member of yourfamily or a friend or aquaintance couldbecome afflicted.In Germany alone, cardiovascular ill-nesses are responsible for about400,000 deaths each year. It is onlythrough intensive research, educatio-nal advertising, development of newmedication and treatment, that themortality rate has been lowered.

If you would like to support our causewith the enrolment as a member orwith a donation, you will not only bemaking a contribution for the advance-ment of medicine but you will alsohelp us in an endeavour which - aseveryone knows - may be of benefit toyou at one point or another.

Friends of the German Heart Centre Foundation

The Friends of the German Heart Centre Foundation was founded in 1986 to aidthe Heart Centre in achieving its goals by providing financial support from donations and membership fees.

Förderverein Deutsches Herzzentrum e. V.attn. Mr. Köppen

TreasurerLazarettstr. 36

80636 MünchenGermany

[ ] I would like to become a member of the Friends of the German Heart Centre Foundation.

[ ] I will submit my yearly membership fee of the amount of Euro € ________ (minimum yearly amount 60.- €)

by bank transfer:Stadtsparkasse München, BLZ. 701 500 00, Kto-Nr. 33 33 36

[ ] You may book my yearly membership fee directly from my bank accountof the amount of Euro € ________ (minimum yearly amount 60.- €)

Bank _____________________________________________________________________________Bank code ________________ Account number _________________________________________

Date _________________ Signature ______________________________________________

[ ] I do not wish to become a member but would like to support your work with a donation.Please send me a bank transfer form.

Name ____________________________________________________________________________Street ____________________________________________________________________________Zip ____________________ City ____________________________________________________

Date _________________ Signature _______________________________________________

ADear patient,

This alphabetical index is to provide you with a helpful guide and informationsource during your stay at the Heart Centre.

Do not hesitate to ask questions, express your wishes or make suggestions.

We wish you all the best and above all, a rapid recovery and good health during your stay in our hospital.

Yours, Management

Accompanying family:The Ronald McDonald House is avai-lable for the accommodation of pa-rents or relations, accompanying pae-diatric patients. Information on othermeans of accommodation can be ob-tained in the wards or at the office ofthe Head Consultant of the respectivedepartment. The social workers arealso available with plenty of adviceand information.

Admission:The admission of patients is done onthe ground floor opposite the mainentrance. It is open from Monday to Thursdayfrom 07:00 - 15:45 hrs and on Fridaysuntil 13:30 hrs. Outside these opening hours, admis-sion is done directly on the wards.

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From A-Z

Food/ Menu:Our aim is to offer you a high-gradeand above all, variable range of deli-cious food. Please do not forget thatthe diet eventually prescribed for youduring your stay may differ from yourusual eating habits. The menu is validfor one week and is released on Sun-days. It can be found either in therooms or on the information board ofthe wards.

Hairdresser:An appointment can be made, throughthe nursing staff, with a hairdresserwho comes to the hospital.

Hospital volunteer service:A volunteer service, called "Green La-dies", will be at your service to assistin minor errands or whenever you needsomeone to talk to. Inform the nur-sing staffs on your ward or leave amessage at the information desk onthe ground floor, whenever you wishto use the services of these volunteers.

Drinks:The supply of drinks is an integral partof our service in our hospital. You willbe supplied with the type and amountof drinks appropriate to your health.In case you wish and are allowed todrink something else, you may pur-chase this at the coffeeshop or at thevending machine on the ground flooropposite the staff cafeteria.

Fellow patients:We endeavour to place "suitable" patients together in the same room.Naturally, that does not always workout, so we ask for mutual respect,consideration and understanding during your stay in hospital.

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Coffeeshop:Drinks, snacks, magazines and routi-nely needed articles may be purcha-sed here. The coffeeshop is located inthe vicinity of the main entrance.

The opening hours are:Mo.– Fri. 07.30 – 17.00 hrsSat. 09.00 – 10.00 hrs

13.00 – 17.00 hrsSun. 13.00 – 17.00 hrs

Room service possible: Phone: +49 (0) 89 1218-1035

Counseling and training:The following counselling services areavailable:@ Dietary advice for patients by dieti-

cians can be obtained through the heads of the individual wards.

@ AG Self-control of anticoagulation (ASA) Appointments can be obtainedthrough the telephone number: +49 (0) 89 1218-1012.

@ Genetic counselingInformation on this subject can be obtained from the heads of the in-dividual wards

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Patient rooms:The patient rooms are modern double-bed rooms. Every room has a combinedshower and water closet. A cupboardand a safe is also available for yourpersonal effects. Space is limited,kindly bring only your most necessarybelongings to the hospital. The Ger-man Heart Centre cannot be liable foryour valuables or cash. We offer how-ever the option of depositing valuablesin the hospital safe. The nursingstaffs will gladly inform you with thenecessary details.

Physiotherapy:The department of physical therapyprovides invaluable care especially inproviding excellent post-operativetherapy and treatment. A highly moti-vated team of physiotherapists worksat the German Heart Centre.

Radio:The transmission facility installed inthe hospital is made to serve as asource of information and entertain-ment. The nursing staff will explainhow to use the radio to you. Kindly ensure that no one is disturbed.

Road description:See graphical road map page 48/ 49

Self-help groups:Self-help groups have emerged fordifferent groups. Information on therange of offers or assistance can beobtained from the relevant depart-ment. Information materials on the self-help groups can be found on thewards.

Information:The Information desk can be found in the vicinity of the main hall and isat your disposal with all necessaryinformation.

Mails/ Letters:There is unfortunately, no letterbox inthe hospital. You may handover fran-ked mail to the nursing staffs or atthe information desk on the groundfloor.

Parking spaces:Unfortunately, there are only a limi-ted number of parking spaces in ourshort-term parking space which is notfree-of-charge.

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Stamps:Stamps can be obtained at the recep-tion or at the postal station.

Taxi:The cost of using taxis for trips to andfrom the hospital is assumed by thepatients. Your health insurance willinform you about reimbursement op-tions. Taxis may be ordered throughthe information.

Smoking:The German Heart Centre is a "non-smoking" hospital. Smoking is notpermitted in the entire building.

Social services:Social services can be found on theground floor, room 0-116 beside theCoffeeshop. It can be reached under the phonenumber +49 (0) 89 1218-1037 and +49 (0) 89 1218-1040. In co-operation with the public socialwelfare department, the social ser-vices department provides help andadvice on:@ Rightful entitlements@ Handicap registration@ Financial issues@ Official and bureaucracy issues@ Arranging follow up treatment

Spiritual welfare and Church service:@ A catholic hospital minister works

in our establishment and visits the patients regularly. His office is loca-ted on the ground floor in the atriumand can be reached by phone under 089/1218-1036. The consultation hours of the ca-tholic minister are:Mondays - Fridays 13.00 - 14.00 hrs

@ The protestant hospital ministercan be requested to visit the houseon demand, through the information.

@ You may also leave a message forthe minister at the information.

@ Church services are held everySunday at 09.00 hrs in the worshiproom in the atrium on the ground floor.

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Telephone/ Mobile phone:If you have no telephone at your bed-side, there are two public telephones(coin telephone, card telephone) inthe atrium on the ground floor at yourdisposal as well as one further publictelephone on the 2nd floor oppositethe elevator. You may of course, be given a bedside telephone for a dailycharge of € 2.30. For this purpose,you will be given a card which youmay load for making calls, on thecharging device on the ground floorbeside the paediatric out-patient de-partment. Kindly observe the "Infor-mation on the usage of patient tele-phone", which you receive on admis-sion. For reasons of safety, the usage ofmobile cellular phones is not permit-ted at the German Heart Centre.

Television:Patient rooms are fitted out with tele-visions sets which can be used free-of-charge. Kindly ensure that your fel-low patients agree with your usage ofthe television at all times, and thatno one is disturbed. Do not forget therest periods and use a headphone ifnecessary to avoid disturbing others.

Valuable personal effects:Valuable personal effects may be de-posited if necessary, at the cashier'soffice. It is located at the entry lobby(also see "Hospital rooms").

Visiting hours:Visiting hours vary from ward to ward.Nursing staffs will provide precise in-formation on visiting hours. In excep-tional cases, visiting hours may berestricted by the physician or when amedical or nursing procedure may re-quire visitors to leave the room. Weask for your co-operation.Children under the age of 14 are notallowed to visit the children's ward.Children are permitted in the generalwards and the intensive-care unitsonly after consultation with the physi-cian treating the patient concerned.

Numbers of patients and procedures

@ Number of inhospital patients

@Cardiac Catheterisations in adults

@Cardiac Catheterisations in children

@Electrophysiological Procedures

@Number of Cardiovascular Operations

@Number of Open-Heart Procedures

@Number of Open-Heart Procedures in Children

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The German Heart Centre Munich issituated inLazarettstraße 36 in 80636 Munich,i.e. in the heart of Munich.

You can reach us quite easily by car, rail,air or public transport:

By rail

Take the underground train Line U1 fromthe train station, to the train stop Mail-lingerstraße or take the Tram number 20or 21 to Lothstraße. From here, the remai-ning distance is only a few minutes onfoot.

By air

There is an S-train from the Franz-Josef-Strauss airport to the main railroad sta-tion. From there, take the undergroundtrain line U1 to the train stop of Maillinger-straße or take the Tram number 20 or 21to Lothstraße. From here, the remainingdistance is only a few minutes on foot.

By public transport

Take the underground train line U1 to the train stop of Maillingerstraße

Tram number 20 or 21to Lothstraße

By car

Lazarettstraße can be accessed directlyfrom Nymphenburger Straße or DachauerStraße.There are a limited number of parkingspaces in front of the house.

How to reach us

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A 95 from the direction of GarmischTake the Garmisch highway A95 heading for Munich till the end of the highway. Take a left at theCentral Ring West. Follow the central ring till the bridge of Donnersberg is left behind. Exit thering shortly before entering the tunnel and take a right into Nymphenburger Strasse in the direc-tion of the city centre. In Nymphenburger Strasse, take a left into Lazarettstrasse (3rd street).

A 96 from the direction of LindauTake highway A99 to the direction of Munich until the end of the highway, this leads automatical-ly to the central ring West. Follow the central ring until the bridge of Donnersberg is left behind.Exit the ring shortly before entering the tunnel and take a right into Nymphenburger Strasse inthe direction of the city centre. In Nymphenburger Strasse, take a left into Lazarettstrasse (3rdstreet).

A 8 from the direction of StuttgartTake the highway A8 in the direction of Munich till the end of the highway. Enter the traffic circleand take the 3rd exit. Continue to follow Verdistraße. Along the line, Verdistrasse becomes Ama-lienburgstrasse which in turn also becomes Menzinger Strasse and finally ends up as Notburgas-trasse. Take a left at the Roman square. Follow the street until it ends up automatically, in Nym-phenburger Strasse. Take a left in Nymphenburger Strasse into Lazarettstrasse (3rd street).

A 9 from the direction of NurembergTake the highway A9 in the direction of Munich until the end of the highway and follow the cen-tral ring West in the direction of Lindau or Garmisch-Patenkirchen. From the central ring, take aleft into Nymphenburger Strasse, take a left again into Lazarettstrasse.

A 92 from the direction of DeggendorfAt the highway junction AK Neufahrn/68/Eching-Ost change over from A92 to A9 in the directionof Munich. Proceed to the end of the highway and follow the central ring West in the direction ofLindau or Garmisch-Patenkirchen. At the central ring, take a left into Nymphenburger Strasse inthe direction of the city centre, take a left again into Lazarettstrasse (3rd street).

A 94 from the direction of PassauTake the A94 until the end of the highway, this leads automatically to the central ring West. Fol-low the central ring until the bridge of Donnersberg is left behind. Exit the ring shortly before en-tering the tunnel and take a right into Nymphenburger Strasse in the direction of the city centre.In Nymphenburger Strasse, take a left into Lazarettstrasse (3rd street).

A 8 from the direction of SalzburgTake the A8 in the direction of Munich-Giesing until the end of the highway, this leads automati-cally, to the central ring West. Follow the central ring until the bridge of Donnersberg is left be-hind. Exit the ring shortly before entering the tunnel and take a right into Nymphenburger Stras-se in the direction of the city centre. In Nymphenburger Strasse, take a left into Lazarettstrasse(3rd street).

Information on the Internet

You will find more information aboutthe German Heart Centre Munich, the departments and institutes, yourhospital stay and much more.

Visit our internet site at:

www.dhm.mhn.de

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Contacts

General Management

CEO: Robert Siegert

Telephone: +49 (0) 89 1218-1701Fax: +49 (0) 89 1218-1703dhm@dhm.mhn.de

German Heart Centre MunichLazarettstraße 3680636 MünchenGermany

Telephone +49 (0) 89 1218-0Fax +49 (0) 89 1218-3053

Institute for Anesthesiology

Director of the Institute: Prof. Dr. Peter Tassani-Prell

Telephone: +49 (0) 89 1218-4611Fax: +49 (0) 89 1218-4613Anaesthesie@dhm.mhn.de

Departmentof Heart and CirculatoryDiseases

Director of the Department: Prof. Dr. Albert Schömig

Telephone: +49 (0) 89 1218-4011Fax: +49 (0) 89 1218-4013Kardiologie@dhm.mhn.de

Ambulance:Telephone: +49 (0) 89 1218-4005

Departmentof Paediatric Cardiology andCongenital Heart DiseaseMedical director of DHM andDirector of the Department: Prof. Dr. John Hess

Telephone: +49 (0) 89 1218-3011Fax: +49 (0) 89 1218-3013Kinderkardiologie@dhm.mhn.de

Ambulance:Telefon: +49 (0) 89 1218-3005

Nursing Directorate

Director of Nursing Care: Burkhard Köppen

Telephone: +49 (0) 89 1218-1001Fax: +49 (0) 89 1218-1003Pflegedirektion@dhm.mhn.de

Departmentof Cardio-Vascular Surgery

Director of the Department: Prof. Dr. Rüdiger Lange

Telephone: +49 (0) 89 1218-4111Fax: +49 (0) 89 1218-4113Herzchirurgie@dhm.mhn.de

Institute for Laboratory MedicineDeputy medical director of DHM andDirector of the Institute: Prof. Dr. Wolfgang Vogt

Telephone: +49 (0) 89 1218-1011Fax: +49 (0) 89 1218-1013Labor@dhm.mhn.de

Institute for Radiology and Nuclear Medicine

Director of the Institute: Dr. Stefan Martinoff

Telephone: +49 (0) 89 1218-4511Fax: +49 (0) 89 1218-4513Radiologie@dhm.mhn.de