Major Problems Remain at Ljubljana's New Children’s Heart Department (Feature)

By , 13 Aug 2018, 09:04 AM News
The University Medical Centre in Ljubljana The University Medical Centre in Ljubljana

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STA, 13 August 2018 - More than half a year since the government founded the National Institute for Congenital Heart Disease in response to dysfunctional child heart cardiology at Slovenia's main hospital, problems persist. 

UKC Ljubljana used to treat children with congenital heart disease from all over Yugoslavia, however, problems that have been piling up for more than a decade have led to a complete collapse of the system.

A clinical department for paediatric surgery and intensive therapy at UKC Ljubljana was set up in 1974 and in the early 1980s cardiac surgeon Jolanda Jezernik Leskovšek blazed a trail in advanced surgical treatment of complicated congenital heart defects in newborns.

Further improvements and new procedures were introduced by paediatric heart surgeons Miro Kosin, but his sudden retirement due to injury in 2005 left the hospital without an adequate successor.

Following a two-year stint at the hospital of a Slovakian surgeon, UKC Ljubljana hired Israeli surgeon David Mishaly, with the intention that he should train young local heart surgeons to operate on the smallest children.

However, after a few years, controversy arose over Mishaly's fees, and later an international inquiry appointed by the Medical Chamber found a number of systemic flaws in his programme.

Despite allegations of medical errors and of unnecessary deaths, there have been no conclusive findings to date, and after cooperation with Mishaly ended in 2014, problems kept piling up to the point when most Slovenian specialists have left the programme.

To deal with toxic relationships among staff, which have been producing scandals, the government decided to start a new system from scratch by setting up the National Institute for Congenital Heart Disease as an independent public institution in December 2017.

It was Igor Gregorič, an internationally acclaimed Slovenian surgeon, who was entrusted with the mission of developing a structure that would restore a congenital heart surgery service in Slovenia by international standards, something that he says Slovenia has not had for 12 years.

Gregorič, who heads the new institute's board, has told the STA in an interview that the new institution will fully assume care for children born with heart defects from UKC Ljubljana as soon as that will be safe, that is not for at least a month or two longer.

The time will depend on how soon it will be able to secure required staff, equipment, funding and space. He says that even though agreements have been made and signed, obstacles keep arising.

The institute will have its own paediatric cardiologists, cardiac surgeons, anaesthetists and paediatric intensive care specialists. "The staff is currently impossible to hire in Slovenia alone, which will put off making the programme fully operational for a while longer."

The problem could be solved in cooperation with the UKC, however "there doesn't seem to be the willingness at the UKC". Gregorič believes the hospital should provide more support to the institute, while it should also realise that the current organisation of paediatric cardiology is inappropriate.

Gregorič, who heads the surgical division at the Memorial Hermann Center for Advanced Heart Failure in Houston, US, says that the new Slovenian institute is "based on the latest global trends in the field and will provide the best treatment of children with congenital heart disease in the long run".

Due to staff shortages in Slovenia, the institute will need to rely on foreign specialists for a while, despite the high costs. For up to a year longer some children requiring the most demanding surgeries would still need to be taken for surgery abroad.

"The important thing is to ensure that young Slovenian trainee doctors get training with the top specialists. There are no such in Slovenia in the field."

Foreign experts brought by the institute to the UKC have so far operated on five children, all of which were emergency cases. Meanwhile, UKC Ljubljana has hired specialists from Prague who are coming to operate on children in Ljubljana at times.

"Foreign experts have noted that there is in fact the need for between 150 and 200 surgeries a year, even though there have been so far only between 100 and 120 a year. This means that some children have not been operated on even though surgery could help them."

Despite good cooperation with the staff at UKC, all four foreign doctors hired by the institute noted "a serious lack of communication between various medical services and a lack of advanced approach to the treatment of children".

Gregorič pointed out that apart from systemic and organisational issues, the collapse of the Ljubljana paediatric cardiology was "absolutely also provoked by the broken down personal relationships".

He said that the only way to guarantee children's safety by international standards is to have the whole surgical and cardiological team present every day, something that the new institute will provide.

On Friday, the institute confirmed that one of the children operated on by foreign cardiac surgeons had died suddenly from complications after surgery. Gregorič believes that the treatment was conducted in accordance with the standards, but he called for oversight by an independent international commission.

It is not optimal for foreign specialists to come to the UKC, taking turns after a few weeks, but it is the only possible solution to set up congenital heart surgery care in Slovenia, Gregorič told reporters, adding that the system had not contributed to the child's death.

Jorge Salazar, the paediatric cardiac surgeon from the US who had operated twice on the girl that later died, said that the child had convalesced well after the second operation, when he was notified of her sudden death by the hospital and her parents. He said the parents thanked him for trying to save their child.

The institute's acting director Brane Dobnikar said that they have so far sponsored the work of two paediatric cardiologists and three paediatric cardiac surgeons at the UKC Ljubljana. The surgeon who arrived on Thursday will stay at the hospital for a week or longer if necessary.

The UKC has meanwhile urged for the centre to become fully operative as soon as possible. The hospital's medical board said that the unclear division of responsibilities poses a risk for patients.

Unless the centre becomes fully functional soon and takes over the patients in full, its doctors should limit themselves to providing counsel, the board said.

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