The first 100 years of “Városmajor” - The ongoing history of the Heart and Vascular Center

The first 100 years of “Városmajor” The ongoing history of the Heart and Vascular Center

The first 100 years of “Városmajor” The ongoing history of the Heart and Vascular Center

Managing Editor Béla Merkely Editor and interviewer Pálma Dobozi Editor-in-chiefs Attila Nemes Zoltán Szabó Authors György Acsády, György Balázs, Dávid Becker, Elek Bodor, László Entz, János Gál, István Hartyánszky Jr. Kálmán Hüttl, Ferenc Horkay, Violetta Kékesi, Orsolya Kiss, Béla Merkely, Attila Nemes, Lajos Papp, Péter Sótonyi, Péter Sótonyi Jr., Zoltán Szabó, Zoltán Szabolcs, Zoltán Szeberin, Zsolt László Szelid, Ágoston Szél, Katalin Széphelyi, Andrea Szűcs, Tivadar Tulassay, Hajnalka Vágó, Mária Windisch Photos Ágnes Szél Balázs Merész © Semmelweis Publishers, 2015

ISBN 978-963-331-333-6 All rights reserved. No part of this work covered by the copyrights hereon may be reproduced or copied in any form or by any means – graphic, electronic or mechanical, including photocopying, recording, taping on information storage and retrieval systems – without written permission of the authors and the publisher.

Responsible editor: László Táncos Make-up editor: János Békésy Cover design: László Táncos SKD: 470 Printed and bound by: Mester Nyomda

Contents Presidential welcome ...................................................................................................... 9 The token of the future in Hungarian cardiovascular medicine: the past 100 years of “Városmajor” ........................................................................................... 9

Foreword ........................................................................................................................ 15 – or what happened in the world since the establishment of Janos Sanatorium .... 15

János Sanatorium (1912–1951) ......................................................................................... 25 From the Belle Époque to the “people’s democracy” ............................................... 25

Some things continue, some things get started .............................................................. 35 Postgraduate Surgery Training Clinic (1951–1957) ................................................. 35 Interview with Professor Endre Pintér, director of the former Lung Surgery Department ..... 46 Interview with Professor Ferenc Robicsek, who was a pioneer of cardiac surgery not only in Városmajor, but in North-Carolina as well ........................................................................ 48

Cardiology hits its stride .................................................................................................. 55 4th Surgery Clinic (1957–1975) .................................................................................. 55

Professions in time .......................................................................................................... 72 History of the Experimental Laboratory (1966–2009) ............................................. 72 Interview with Professor István Besznyák, tumor surgeon with Széchenyi-award, former director of the lung surgery department ............................................................................ 89

The pioneer of vascular surgery ...................................................................................... 93 National Institute of Vascular Surgery (1975–1981) ................................................ 93 Interview with Professor Péter Gloviczki, who started his career in Városmajor, and now serves as chairman of the American Society of Vascular Surgeons ............................................. 109

From motorized surgery to heart transplantation ........................................................... 115 Department of Cardiovascular Surgery (1981–1992) ............................................... 115

Professions through time ................................................................................................ 133 The essence of modern cardiovascular surgery: diagnostic imaging .................... 133

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New approaches in demand ........................................................................................... 145 Department of Cardiovascular Surgery (1992–2003) .............................................. 145 Interview with Professor Csaba Dzsinich, who worked at the Vascular Surgery Department of Városmajor for almost 40 years, and established several new procedure .................... 156

The expansion of cardiovascular medicine – modern cardiology, and minimal invasive therapy comes to the forefront ...................................................................................... 163 Cardiology Center, Heart Surgery Clinic, Vascular Surgery Clinic (2003–2012) . 163

Professions through time ................................................................................................ 186 The history of anesthesia and intensive therapy at Városmajor ............................. 186

Our Vision ....................................................................................................................... 193 – at the Városmajor Heart Center ............................................................................. 193

The centennial year: 2012 ................................................................................................ 215

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“Those who fail to learn the lessons of history are doomed to repeat them.”

George Santayana

Presidential welcome The token of the future in Hungarian cardiovascular medicine: the past 100 years of “Városmajor”

When I was asked by Prof. Béla Merkely, director of the Heart Center, and László Táncos, director of the Semmelweis Multimedia Studio, to write a preface to a book commemorating the 100 year old clinic, I promptly agreed and thought of it as a quick routine task. However, after receiving a portion of the chapters in editing, I realized that this book would be much more than just the chronology and documentation of the clinic’s internal affairs.

Various co-authors put together an exciting, high-quality combination of historical and scientific history overview, rich in factual and cultural details. The clinic, once a hydriatrist sanatorium belonging to the Israelite synagogue, became a surgeon training clinic over time. The various stages of this change are described with fascinating details.

The story also includes references to famous Hungarian poets and writers, such as Endre Ady, Mihály Babits and Dezső Kosztolányi, as well as actresses and actors, such as Pál Jávor and Mari Jászai. This era is marked by several historical events, such as the organization of the Hungarian Scout Association, the publication of Mein Kampf, the Titanic-catastrophe, as well as the first heart transplantation.

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This book is unique, not only for its rich historical details, but also for its style. The authors include not only the masters of cardiology, but members of the younger generation as well, bringing with them vitality and diversity. As the reader immerses in the tales of history, and then learns about the vision of the future, the content of the book, colorful with original photos, quotations and interviews, provides a fascinating experience. This journey begins with: “Once upon a time, there was a famous clinic...” To this, as the director of the Semmelweis University, I can only add: the famous clinic is now stronger than ever, with a bright future ahead!

In the first era, between 1912 and 1951, the institution, known as János Sanatorium, had the following main sections: Gynecology and Obstetrics, Surgery, and Internal medicine.

The authors of this chapter did not have much data or personal experiences available to them. Following 1951, chapter divisions usually follow time periods of directors or leaders of the institution.

The chapter titled Some things continue, some things get started, commemorate the Littmann-era (1951-1956). Apart from the impacts of a dictatorial political system, this chapter outlines the role of physicians at the clinic in providing competent care for those who received gun-shot injuries during the revolution of 1956.

The chapter titled Cardiology hits its stride (1957-1975), discusses the 4th Surgery Clinic, directed by Professor Kudász. This era includes the past-revolution transition, pacemakertherapy, and the consolidation of surgery programs. One section deals with the newly established Laboratory of Circulation Research, and with the contributions of Sándor Juhász-Nagy.

The National Institute of Vascular Surgery owes its existence to Professor Soltész, who is known as the pioneer of vascular surgery. Due to his early death, this era (discussed in “The pioneer of vascular surgery, 1975-1981”) was rather short, but included the emergence of a vascular surgery program within the General Surgery Department.

The chapter entitled From motorized surgery to heart transplantation presents life in the Department of Cardiovascular Surgery (1981-1992) under the direction of Professor Zoltán Szabó. This era includes international-level cardiac surgeries, the development of 10 Th e

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diagnostic imaging (CT and MRI), and the establishment of the surgery section still in use. The era closes with the first successful adult heart transplantation. One section is devoted to how diagnostic imaging came to the forefront.

The crowning event of the next decade (1992-2003) is the opening of the Cardiovascular Center. The chapter entitled “New approaches in demand” discusses the emergence and expansion of invasive therapy, alongside surgery during this era.

A more complex era (2003-2012) follows in the life of the institution. The chapter entitled The expansion of cardiovascular medicine – modern cardiology, and minimal invasive therapy comes to the forefront depicts a time when the traditional clinical structure broke up into three separate clinics in Városmajor (Vascular Surgery, Cardiac Surgery, and Cardiology), to be united again under a unified approach to medicine. One section overviews the anesthesiology and intensive therapy functions of the institution, developing alongside surgery functions.

The chapter entitled Our Vision – at the Városmajor Heart Center presents recent history, with reference to the consolidation of the medicinal and educational structure, the role of the institution in providing regional cardiovascular care, stressing the importance of unified cardiology approaches. Vascular neurology and cardiothoracic surgery are also mentioned within the same framework. While vascular surgery, cardiac surgery and cardiology have their own departments in the educational system of medical and residency training, vascular neurology and cardiothoracic surgery classes are taught in department groups.

This chapter is a fitting cap on the 100 year old historical figure presented in the book.

This vision ensures success in the future. Starting from János Sanatorium, remembering and relying on the past, we reach the 21st-century, unified concept of a university cardiovascular center by the end of the book, where Semmelweis University ensures the highest level of training for medical students, and the highest level of medical care for patients.

In the preface of this centennial edition, may I quote from a former president of our university, Attila Nemes (in Fecsegések, firkák, fehérben. Private edition, 2008): “What if, on a late-night home-bound walk, I noticed myself a step ahead, getting the key and walking 11 Th e

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into my home. What would I do? Would I go in as well? Or would I stay outside, since I am in already?”

Experiences of the last few decades prompt this feeling. Three disciplines: vascular surgery, cardiac surgery, and cardiology became separate clinics and educational departments, only to unite again in a holistic approach, forming a unified Department of Cardiovascular Surgery, one Heart Center at the end. I suspect we will not need another 100 years to learn the lessons of such rapid change. The Semmelweis University looks at Városmajor as a unique treasure, for the medical, educational and research work of the institution have always resulted in much success both in medicine and science.

As president, all I can wish for is the clinic to preserve its reputation, preserve its ability to keep up with rapid change, and use the experiences of the past to face yet newer challenges in the future.

Budapest, October of 2012

Dr. Ágoston Szél

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Foreword – or what happened in the world since the establishment of János Sanatorium

In June 1912, a modern, private clinic with 40 beds was opened under the direction of Dr. Gedeon Simaházi Totth, gynecologist, medical superintendent. Located on Városmajor street, this sanatorium was part of a complex medical center. Located next door, the Városmajor Hydriatrist Sanatorium was already in operation, later to be bought by the Israelite synagogue, in operation by the name of Dániel Biró Hospital. An Israelite alms-house (still there today) was operating just around the corner, providing care for the elderly.

János Sanatorium offered solace for a number of outstanding cultural figures in Hungary. Endre Ady, the famous poet received treatment in 1912 and in 1916, and wrote his last will and testament in 1926, while in residence at the sanatorium. Mari Jászai,

The wild grape covered building of János Sanatorium after the opening

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The fascade of the clinic

the actress, passed away in the sanatorium. In 1933 and in 1938, Mihály Babits, called the Lord of Poets in his era, was also treated here. Artur Görgey, General Officer in the 1848/49 revolution against the Habsburg Monarchy, debated for his role in the surrender of the Hungarian troops, was honored with a memorial plaque on the wall of the building in 1927.

This story starts in 1912. There was not any internet or television, and the radio was still in development. People primarily learned of the news from newspapers. This way, they did not hear of global and local events immediately, but when these news did reach them, they had a more lasting effect, and were discussed at length both at home and in the workplace.

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The parlor. Visitors entered through the main entrance, and after checking in, could visit with the patients in this room

In this book, we undertake to tell the story of a century-old institution. The first 50 years are less well chronicled as the documents are incomplete and the witnesses have long passed away. The past century was full of historical thunderstorms, some of which we will touch upon before getting to the story itself.

From Kalmopyrin to the Titanic At the beginning of our story, in 1912, the French surgeon professor, Alexis Carrell was awarded the Nobel Prize, honoring his accomplishments in angiography, as well as veinand tissue transplantation. (Later, vascular surgery will be an important program at the institution.) At the same year, Richter produced a new medicine, called Kalmopyrin. In domestic affairs, these were the last peaceful years of the reign of Franz Joseph I, while István Tisza became Speaker of the House (the National Assembly). During this year, 17 Th e

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the Hungarian Scout Association was organized on Christian principles. It was also the year of birth for János Szentagothai, anatomy professor; István Örkény, writer; Sir George Solti, chorister; Otto von Habsburg, crown prince; Raol Wallenberg, diplomat; and János Kádár, leader of the communist Hungary – they did not develop immediate connections with institution itself, but had an effect on the world in the years to come. However, all of this faded away at the greatest tragedy of 1912, the sinking of the Titanic ocean liner.

Political thunderstorms, developments in medicine and art The First World War and its aftermath was an era of political thunderstorms, yet it brought great developments in medicine, art and architecture. Shaping the clinic’s future cardiology program, major inventions included the electrocardiograph – for which Willem Einthoven, Dutch physician was awarded the Nobel Prize in 1924 –, and the penicillin, discovered by Albert Fleming in 1928. In 1930, Karl Lansteiner received the Nobel Prize for classifying the main blood groups. Professor Albert Szent-Györgyi also contributed much to this era, receiving a Nobel Prize in 1937.

These were turbulent times for both international and domestic politics. On December th 30 , 1916, the last Hungarian king, Charles IV ascended to the throne, and during the last years of the war, several prime ministers attempted (e.g. István Tisza, Móric Esterházy, Sándor Wekerle) to save the political institutions of the kingdom. The land-allocator count, Mihály Károlyi, however, worked on breaking down the Monarchy, both as prime minister and as president of the Republic. At the same time, political events in Russia had a transitional effect on domestic affairs, and lead to permanent changes following World War II. A prominent patient, receiving care at various intervals: Endre Ady, had a lasting effect on the staff of János Sanatorium.

This turbulence led to the Trianon Peace Treaty, when 2/3 of Hungary’s land was given to neighboring countries.

During this period, Mikós Horthy set out to consolidate the state, and thus, he nominated the renown geography scholar, Count Pál Teleki as prime minister in 1920. Hungary was regaining strength, the National Bank was established in 1924, and a new currency, pengo, was issued in the forthcoming years.

Renown artists produced great creations, Béla Bartók, the musician, composed violin and piano sonatas, and Zoltán Kodály wrote Psalmus Hungaricus (in 1923). Two future athletes of world-fame were born in this era, Laszló Papp (1926), the boxer who was 18 Th e

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Corridor view at János Sanatorium

undefeated in the ring, and Ferenc Puskás (1927), a soccer player and captain of the socalled Golden Team.

Hungary did not enjoy lasting peace, however. Vladimir Iljic Lenin announced the formation of the Soviet Union in 1922, and a year later, Adolf Hitler attempted a coup in Germany, writing his program in “Mein Kampf ” in the months that followed, while he was in jail. Ten years later, he became chancellor, and the first internment camp was established in Dachau. In 1936, civil war struck in Spain, while Mussolini and Hitler created the Berlin-Rome axis. This show of power raised an alarm in several political figures, Pope Pius XI issued an encyclical. Public awareness of the European situation was rather low in the United States, Walt Disney screened his first cartoons in 1924, and the first Oscar Gala was held in 1929.

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Spas have always been an important element in sanatorium treatments and rehabilitation

The Second World War, secularization, and revolution While the First World War did not leave permanent damage in the Városmajor buildings, the Second World War resulted in substantial material and personal loss. The building of János Sanatorium survived much of the war itself, but did not escape the secularization enforced by the soviet-type social system following the war. For a while, it operated as an integral part of the neighboring János Hospital, with one Internal Medicine Department and one Obstetrics-Gynecology Department. Surgical care restarted in 1951, the institution was renamed as the Postgraduate Surgery Training Clinic of the Medical University of Budapest, and Imre Littmann became its director.

1952 saw the emergence of cardiac surgery, and Vascular Surgery Departments were established in the years to come. The first open cardiac surgery in Hungary was conducted at the clinic in 1960. This was a real achievement, taking into account that this field of surgery was still in its developing stage, even in the USA. Between 1953 and 1956, a higher number of closed cardiac valve surgeries were performed at the clinic than anywhere else in the world, except for London.

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In 1956, at the Hungarian revolution against the communist terror, the staff of the clinic provided care for hundreds of injured revolutionists. During the second part of the 1950’s, the famous actor, who performed in Hollywood as well, Pál Jávor had his last amusement in the yard of the clinic, when on the last evening before his passing, he ordered a gipsy band to play his favorite songs and music, his last wish being to amuse himself as he always did. Tivadar Uray, another famous Hungarian actor, was treated here as well.

This was the first institution in Hungary to perform catheter-based cardiac examination, and this is where the adult heart transplantation program started in 1992, 25 years after Christiaan Neethling Bernand performed the first successful human to human heart transplantation in South Africa.

The future, founded on the work of predecessors At the moment, the institution functions as part of the Semmelweis University’s Heart Center, and provides a substantial amount of both regional and national cardiovascular care, coupled with cardiovascular training for graduate and postgraduate medical students, as well as high-level research work in basic and clinical research.

The last hundred years saw soft and hard dictatorships, fake and real democracies come and go, but Városmajor continued to offer high-level patient care through it all. The general staff, physicians, nurses, assistants, and all are aware of the fact that the institution remained the flagship of Hungarian cardiovascular care, even on turbulent seas.

This book is written to look back on predecessors who laid the foundation of scientific work and medical care, yielding the kind of fame and trust which still brings a great number of patients to us at the clinic.

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János Sanatorium (1912–1951) From the Belle Époque to the “people’s democracy” In June of 1912, there was peace still, but the golden days of civil society were coming to an end. Városmajor street 68 belonged to the outskirts of Buda. This is where the sanatorium, then considered modern, was built. This building is now 100 years old.

“The electrocardiograph is a precious device in cardiac diagnosis. Our institution is the only one in Hungary, equipped with a Boulitte-type, string galvanometer-electrocardiograph, highly praised in professional circles...”

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It was rebuilt again and again, following the demands of the time, yet the facade did not change much, except that two bells, the large park and the sun desks disappeared.

We started with 40 beds. There was surgery – primarily –, along with gynecology, obstetrics, otolaryngology, ophthalmology, urology, orthopedics and internal medicine.

Renowned poets in Városmajor Városmajor always offered state-of-theart instruments, no wonder that famous poets, such as Endre Ady and Mihály ­Babits, wrote about the institution. Ady was a tough patient, his personality did not agree with any discipline whatsoever. Yet he had an inner vitality, regenerating him at astonishing speed.

Looking back on a time period spent here, he wrote: “In the Városmajor sanatorium, they beautifully got me back on my feet.”

Endre Ady, treated at János Sanato­rium, passed away on January 27th, 1919.

Mihály Babits, the renowned poet, suffering from laryngeal cancer, received treatments at János Sanatorium for the second time in February of 1938. For the operation, Dr. Rudolf Nissen, the surgeon of German origin was requested, who at the time worked in Istanbul in hiding from the Nazis.

Endre Ady in the yard of János Sanatorium in 1916.

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Then the deeply religious, catholic poet, went to the Városmajor church to ask for a blessing. The renowned poet got so well after the operation and the radiation therapy, that he was strong enough to travel to Italy and receive the San Remo award for his translation of Dante.

Then, just before his death, he delivered his academic inaugural lecture in 1941.

Mihaly Babits in his sick-bed

Several other, then prominent, nowadays not so well known people were treated here. Miklós Kozma, an army officer, number one media director in between the two world wars, died within these walls in December of 1941. Imre Prokopy, lord lieutenant, representative of south-land Hungarians, died here in 1944. Döme Sztójay, prime minister, was treated here with serious flu symptoms in between his resignation and his treatment in Austria.

“Thick black smoke…”

Between 1912 and 1951, two world wars ensued, along with the re-segmentation of Europe, the unparalleled amputation of Hungary, the Holocaust, and the Soviet invasion. The number of beds at the institution doubled by 1942, growing to 80. The war

State-of-the-art radiograms of the time

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The building of János Sanatorium, view from the yard in June 1912

reached János Sanatorium by the end of 1944. In the cellar, patients suffering from various illnesses sought cover, mixing with half-frozen dead bodies.

Tragedies accelerated when the Arrow Cross Administration became even more fierce with the approach of the Soviet troops. The Jewish hospital next door was set on fire.

Memoirs tell of thick black smoke coming out of the sanatorium, the trees and bushes of the inner yard on fire, chairs and sundeck beds becoming a mound of ash, bodies beaten and shot to death everywhere in the hospital rooms, on the corridors, in the spa.

150 people, the staff and patients of the Dániel Biró Orthodox Hospital, some of whom were transferred there from János Sanatorium less than a week before. Servicemen coming to extinguish the fire were held at the point of the gun to watch the building and all within crumble to ashes.

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Systematic developments Hungary celebrates the centennial of the 1848 freedom fight, but there is no freedom to be found!

From a university minute-book of October 1945: “... 13 surgeons were suspended for ‚fascist behavior’ at the 2nd Surgery Clinic. The head of the department was sent to forced retirement after two lawsuits.”

This was the environment of the renown Hungarian surgery.

After the secularization, the sanatorium building was turned into the Buda Common Hospital of the Capital City’s Council, belonging to the János Hospital, providing 160 beds in Internal Medicine, as well as Obstetrics and Gynecology Departments.

This development, however, was quantitative only, not qualitative. The raise in numbers (from 40 to 160!) was at the expense of hygiene and comfort, since it was not accompa-

Operating theatre in the department of surgery

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The sanatorium’s laboratory was considered to rank among the best at the time

nied with enlargement of space. Later, the number of beds was reduced to 140 and then to 120, but that was still three times the original number. Then each director tried to raise the quality by restructuring and airspace enlargement.

Several new hospitals were established throughout the country. The following list indicates the location, the year of establishment, and the number of beds in their Surgery Department.

County hospitals: Pincehely (1952-30), Debrecen (1953-80), Vásárosnamény (1958-50), Bonyhád (1959-58), Miskolc (1959-80), Fehérgyarmat (1963-58).

Town hospitals: Szőny (1945-47), Tata (1945-53), Ózd (1949-87), Kiskunlacháza (1950-70), Jászberény (1946-55), Karcag (1946-80), Mezőtúr (1950-50), Hatvan (1961‑86), Kazincbarcika (1954-87), Komló (1946-50), Nagykőrös (1950-35), Siófok (1965-74), Dombóvár (1969-60), Ajka (1972-66). The Hungarian National Railway Company also built a new hospital in Szolnok (1967-60).

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Victims of the central inventory New methods, developments require the renewal of the equipment or the purchasing of new devices. The post-war decades of seclusion and poverty did not make it possible to import delicate or new surgical instruments, but we still had some of high quality left from before the war. Most of it, however, became victims of the central inventory, when untrained collectors took our precious instruments, equipments and microscopes to inter metal recycling, and smashed them in. We did receive new ones, made of “chamber pot steel”, formerly used for clips and mousetraps, bending right at first use. The scissors were blunt, the made in China blades did not fit into the scalpel handles. The smashing was so complete, that there aren’t any old instruments left to present them in a film or at an exhibition now.

This was the general environment of the developing surgery, in Városmajor as well. Fortunately, devoted “gardeners” attended the unfolding and blossoming of modern surgery in Hungary.

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“Libera per vacuum pousi vestigia princeps, non aliena meo pressi pede.”

(I first planted my footsteps freely on virgin soil, Touched by my feet, no others.)

(Horace: The Epistles. Book I: Epistle XIX, 21-22)

Some things continue, some things get started Postgraduate Surgery Training Clinic (1951–1957) Prof. Dr. Imre Littmann (November 21st, 1913 – August 21st, 1984) Between 1931-37, he concluded his medical studies in Pécs. He started his career at the 9th Military Hospital.

Between 1938-41, he was a trainee at the Surgery Department of the (later) Bajcsy Hospital, and between 1941–42, an assistant doctor at the Bródy Hospital. From 1942, he was a labor draft doctor, in Balassagyarmat and other places. From 1945, he was a junior doctor in the Surgery Department of János Hospital, from 1948, an adjunct at the same place, and between 1949-51, a professor’s assistant at the 3rd Surgery Clinic.

In 1948, he conducted the first closure of the ductus Botalli, dispatching Hungarian cardiac surgery.

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In 1951, he was appointed a university lecturer, and director of the Városmajor Postgraduate Surgery Training Clinic. Here, he initiated machine-supported anesthesia, organized the first heart catheterization laboratory, and established an experimental operating theatre, where several closed cardiac surgeries were conducted. In 1954, he received a Kossuth-award, and in 1955, he defended his doctoral dissertation, as the first surgeon to do so. In 1956, he left Hungary, and worked first in Sheffield, and then in the Toronto General Hospital.

Following his return in 1958, he was senior surgeon at Lászlo Hospital, and from 1960, at the Hospital in Tétényi street. In 1963, he was appointed professor of the 1st Surgery Department of the Institute of Postgraduate Medical Training, and he worked here until his retirement of 1981. He wrote 11 published books (in Hungarian, in German and in Russian), and over 100 other publications.

The beautiful art nouveau building became a surgery clinic in 1951, and was named Postgraduate Surgery Training Clinic of the Medical University of Budapest. The first director was Dr. Imre Littmann, university professor, D. Sc of medicine. Two surgery blocks were created, along with a photo laboratory. The x-ray department received a new heart catheterization department. In 1952, an experimental surgery room, and a laboratory department was instituted at a separate building.

The prime responsibility of the Postgraduate Surgery Training Clinic was instruction in wartime surgery. At the outset, it had a General and a Lung Surgery Department. The Traumatology Department was discontinued at the end of 1952, providing space for the formation of a Cardiac Surgery Department, followed by a Vascular Surgery Department in 1953. At the same year, a library was built at the northwestern corner of the clinic, including classrooms as well.

So, at the time, we had both lung surgery and anesthesiology in Hungary, and the first steps were taken in the field of cardiovascular surgery. There was no vascular replacement, or surgery within the heart chamber, although there were pioneers starting on this path. During this era, there was chest, or cardiothoracic surgery only. Quoting from Professor Pal Keszler: “With the devastation of World War II, the population’s state of health was in ruins as well, largely due to tuberculosis, which was fittingly named morbus hungaricus even in between the two world wars. Surgical treatment preceded effective medicinal treatment in Hungary as well as elsewhere. Classical procedures, such as extrapleuralis ptx, thoracoplastica and phrenicus deactivation (surgical collapsus therapy), were used by excellent general surgeons of the 36 Th e

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time, such as Lajos Bakay, Lipót Schischa, Tivadar Hüttle, Kamillo Vidákovics, and especially by Arnold Winternitz, since the 1920-30’s, but it was Gyula Sebestény, who established cardiothoracic surgery as a separate discipline in Hungary. In the specialized Lung Surgery Departments of the OTI Hospital of Pestújhely, and then of the St. János Hospital, thoracoplasticas were conducted by the hundred.

By the time he was apX-ray equipment at the clinic in the early 1950’s pointed a university professor at the Baross street Surgery Clinic of the Medical University of Budapest in 1947, the surgery procedure attached to his name (pneumothorax mixte) was well known all over Europe.

Until the 1930-40’s, most cardiothoracic surgeries were executed on the thoracic wall, due to tuberculosis. The clear opening of the chest, and removing diseased parts was considered a great adventure, and was put off for a while, but chronic abscessus pulmonis, bronchoectasia for the most part, prompted the pioneers of cardiothoracic surgery (Sauerbruch, Kirschner, Nissen, Graham, Singer, Shenstone, Haight, Crawford, Rienhoff, Sebestény, etc.) to take the over 50% mortality risk it involved.

The development of cardiothoracic surgery was dependent upon solving the problems of the dreaded open pneumothorax, and the challenges of anesthesia in this time period. Auer and Metzer tried to blow in intratracheal oxygen in 1904, Sauerbruch came up with pressure adjustment techniques during the same year (negative pressure in the ventricle, and then positive pressure respiration). Meyer’s equipment called “Universaldruck-kammer” combined the two approaches, but it was positive pressure respiration which later became the basis of modern, closed-system narcosis. Accomplishments of Kuhn, Ombrédanne, Griffith, Clover, Guedel, Waters, Magill and others until the 1930’s, all helped to shape the intratrachael form 37 Th e

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of narcosis that came to be widely accepted later on, together with the basic anesthetic machine type. Thus, a closed system was formed, preventing atelectasis, at the same time providing for the safety of transpleural thoracotomy.

The Hungarian story of intubation narcosis started in 1949, when the first two modern, Boyle-type anesthetic machine arrived from England, one to the 1st Surgery Clinic at Üllői street, directed by Endre Hendri, and the other to the Surgery Department of János Hospital, where Imre Littmann worked. Between 1950 and 1952, additional machines arrived to the 3rd Surgery Clinic (on Fiumei street), to the Children’s Clinic, and to other parts of the country, Debrecen and Pécs, as well as the clinic on Baross street, then considered the fort of cardiothoracic surgery with local anesthesia.

As a fresh doctor at the 1st Surgery Clinic, I was assigned to learn, as an autodidact, the use of the anesthetic machine, along with the modern procedure of closed intratracheal narcosis. In 1948, Littmann was allowed to go on an extended study trip to England, where he studied cardiac surgery in order to then apply at home what he learned. In England, these surgeries were done in intratracheal narcosis, and their experiences came handy to us. However, after 1949, known as the turnover year, we were not permitted to travel any more, so we started with animal experiments, and tried to learn fast. Within a year, the records reported of numerous successful human operations.

This was the state of affairs B. V. Petrovszkij Soviet surgeon found himself in, when in the fall of 1949, he was appointed director of the 3rd Surgery Clinic of the Budapest Medical University. With this appointment, the medical administration did what was expected in all areas – followed suit with Soviet trends. Petrovszkij, however, turned out to be a great choice. Based on the experience he gained in Hungary, he became an outstanding leader of Soviet surgery in the 1960’s. I myself, as a close associate of Imre Littmann, came to the clinic as a young surgeon, and was able to observe the development of Hungarian surgery, especially cardiothoracic surgery, during this era. Petrovszkij was an able surgeon, who gained much of his experience in the war.”

Army-surgeon training What did Professor Ferenc Robicsek think of this surgeon staff? (Quoting from the jubilee yearbook of the Hungarian Society of Cardiac Surgery, published in Budapest, 2003, p. 26) 38 Th e

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“Right after graduating from the medical university, in 1951, one-third of our group was drafted into the army. I spent a few months at a remote army unit, and then I was sent to the 2nd Surgery Clinic of the University in Budapest for basic surgeon training. This institution was a special place at the time.

Rubányi was the professor, but between 1949 and 1951, the institution was led by B. Petrovszkij, a visiting professor from the Soviet Union. The clinic was in close contact with the army, and received army surgeons for basic and extended training on a regular basis. The clinic admitted traumatology patients from the Budapest district in great numbers, providing good training conditions for the army surgeons.

Rubányi, as the appointed leader, lived in the shadow of the Russian professor, whom most of the Hungarian surgeons received with lack of enthusiasm and much reservation. Interestingly, Petrovszkij ended up forming good collegial relationships with the surgeons, and sided with his colleagues in political questions on occasion as well. He established the first blood transfusion station in Hungary. He was an exceptional surgeon, especially in oesophageal surgery.

Imre Littmann was one of the young surgeons, but he attained assistant directorship by the time he was 37. When I arrived at the clinic, Littmann was working on the establishment of the so-called 4th Surgery Clinic, which had only loose connections with the university, and received the name of ‚Postgraduate Surgery Training Clinic’. He was looking for aspiring youngsters, and invited me to join his team. With his intercession, I received temporal leave from the army, which then turned into dismantlement, and I got permanent work at the clinic. Half of the doctors were civilians, the other half, army surgeons, participating in extended training either as residents, or as lecturers. It was a mixed group, Professor Littmann took some in due to political pressure, and others he invited on the basis of professional abilities.

At the clinic, there was a General Surgery Department, led by József Tóth; two Lung Surgery Departments, one led by the old-fashioned Imre Ungár, the other by the talented young Pál Keszler. The Ventricular Surgery Department was led by Lajos Soltész. Amusingly, I was appointed to lead the Cardiac Surgery Department, as an assistant professor, only two years after graduating from the university.

Littmann wholeheartedly advanced the development of cardiac surgery, along with his adjunct, Antal Temesvári. The three of us made a good team, dividing the surgeries in even proportions among ourselves. This ad hoc team started the establishment of cardiac surgery in Hungary. At the same time, and pretty much on the same level, Professor Kudász in the city of Pécs was also involved in cardiac surgery, but there wasn’t much contact between the two groups.”

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Imre Littmann became director of the clinic. His study trip to England further inspired the already ambitious young surgeon, whom Dr. Attila Nemes once called the root of development in domestic cardiovascular surgery.

For best authenticity on these decisive years, we turn to the accounts of eyewitnesses.

Dr. Imre Szabó, whom everyone called uncle Ricsi, said the following in the so-called green book, published for the clinic’s jubilee: “Ricsi, uncle Ricsi... Who’s that? I acquired this nickname in high-school. Children gave one other all kinds of silly names, they called me Imricsi from Imre, and then shortened it to Ricsi.

It stayed with me. When I came up to Budapest, I lived in a dormitory. I assumed that since no one knew me, the Ricsi name would disappear. But an old classmate came along, and the name remained. Everyone calls me so. If anyone asks for Dr. Imre Szabó, no one knows who that is, but if they say uncle Ricsi, everyone knows.”

As a Swiss watch…

Dr. Imre Szabó, everyone’s uncle Ricsi, goes on to say in this “green book”: “Reconstruction started. In line with the collectivist view of the time, the small rooms were turned into 10-12 bed patient rooms, of course at the expense of bathrooms and toilets. Later I met something that resembled their beautiful glass tiles in the Schönbrunn Hotel of Wien.

The art nouveau, lead glass doors at the end of Janos Sanatorium’s long corridors were eliminated as well, only two of them remained in token. The staff ’s separate building became the “experiential surgery room”. This is how the clinic’s building was reconstructed at the time.

Due to Littmann’s great organizing, all that was necessary for work at the clinic soon took shape. He renovated the two surgery rooms and the ex-ray equipment, and furnished the experiential surgery room, He brought a small part of the doctoral team from the 3rd Surgery Clinic with him, the rest of the team was made of young surgeons summoned from public hospitals, this is how I came to be part of the clinic.

Littmann was the youngest Hungarian surgeon professor. He was an excellent leader, the clinic was characterized by order, discipline and exactness. He started the morning conference right at 8am, the afternoon visit was exactly at 2pm. Clear conception, exact execution, and the clinic was like a Swiss watch.

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surgery programs: cardiac surgery and vascular surgery. The youth had to spend half a year at each of these special departments. They had to learn intratracheal narcosis, catheter-based coronary interventions, angiography, and chest monitoring. His subordinates were expected to study, to educate themselves. There was order in everything. White cap, mask, and white yarn gloves were mandatory in dressing. Leaving the clinic before 4pm was not possible, except with a professor’s clearance. Free time had to be spent at the library. Teams worked at the experiential laboratory, all the youth were scheduled.

The staff of the young clinic was young as well, the 36 year old professor was second to the oldest. The cardiology docent, István Kunos, was a few years his senior, and had to be called uncle Pista. Several members of this young team, chosen by Littmann, became professors and senior doctors of various departments later on.

Imre Littmann’s style of governance I can only praise. All important questions were discussed at conferences, and everyone was welcome to contribute. Then he summarized what was said, made a decision, and everyone followed suit. At a conference in the summer of 1953, he announced that cardiac valve surgeries would be initiated. The first 100 patients had to

Surgery room in the early 1950’s

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be selected with great care, because he wanted to prove that this operation could not only be done, but with good selection, the risk was not higher than that of a gastric surgery. Three years later, in October 1956, he reported on 500 operations at a surgeon meeting. This number was not exceeded anywhere, except for London.

This was a unique accomplishment, especially with the given the circumstances. We had neither anesthetic machines nor anesthesiology assistants, but did it all by ourselves. There was no intensive care unit, no central oxygen supplies or plastic strings. We had makeshift tool trays, ancient surgical tables and lamps, 30 Celsius surgery room temperature in the summer, and a lot of enthusiasm.

Effects of the ‚Rákosi era’, the proletarian dictatorship did not leave the clinic unaffected. It was not enough to add new surgical programs, we had to enlarge our knowledge of current political issues as well. Looking back, it now seems humorous how sober, accomplished surgeons, read aloud to members of their department from the daily party papers during the designated ‚free people’s half an hour’. Then there were the monthly political seminars, reviewing the classic, ‚eternal’ works of Lenin or Stalin, falling on rather disinterested ears, disturbed here and there by uncle Pista’s snoring.”

The new surgery programs produced several leadership characters. Some of those who started their careers during this time period include: –– Dr. Imre Littmann, the founder, “the root”, who fulfilled leadership roles elsewhere as well.

–– Dr. Imre Ungár, who became the leading lung surgeon of Korányi Hospital.

–– Dr. Pál Keszler, leading lung surgeon until his retirement.

–– Dr. Antal Temesvári, who replaced Dr. Attila Arvay as director of the National Cardiology Institution, and continued the modernization of cardiac surgery.

–– Dr. László Erdélyi, who directed the Surgery Department of the hospital belonging to the Ministry of Home Affairs.

–– Dr. Endre Pintér, directing the Surgery Department of Margit Hospital for decades.

–– Dr. Ferenc Robicsek, who went to the U.S., and had an internationally renown career in cardiac surgery.

–– Dr. Iván Loblovics, a leader at the Surgery Department of the Szombathely City Hospital.

–– Dr. Alajos Padányi, a leading surgeon in the town of Körmend.

–– Dr. József Tóth, who became a renown senior physician of the Surgery Department in the town of Eger.

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–– Dr. Lajos Soltész, whom we will yet mention as department director, the “vascular pope”, an advocate of angiology till his deathbed.

–– Dr. Tihamér Lónyai, Dr. Károly Sárközy, and the list could continue. Many learned the basics here, on which they could build later on.

1956 casualties at the clinic October 23rd of 1956 brought a great change in the life of the clinic: “During the first few days, only those who lived nearby were able to come to work. Those who lived on the other side of the Danube, could not come for a while, because the bridges were blocked. In the meantime, truckloads of casualties were brought in: a mixture of Hungarians and Russians. We had to operate a lot, the 3 or 4 surgeons we had were assisted by other colleagues, such as the pathologist and the physiologist. The latter fled the country later on, but the former took a fancy and became a cardiac surgery professor. Who knows what a revolution may bring?”

The injured were on litters in a row in front of the clinic. Rumors tell of 40 operations, the stories can be documented with the help of surgery logs from October-November of 1956. We only have data from one surgery log, below is a list of the most severe cases: –– “József S. 59 year old driver, gun-shot injury, October 24th, 1956, 16.30.

–– Ede B. 26 year old, sacralis gun-shot wound, October 24th, 1956, 17.30, re-operated on October 31st.

–– István Sz. 20 year old locksmith, abdominal gun-shot wound, October 24th, 1956, 17.40 –– St. L. J. 22 year old under-worker, gun-shot wound, October 24th, 1956.

–– István J. 36 year old painter, leg wound, October 24th, 1956. December 6th, limb amputation.

–– Béla Cs. 34 year old under-worker, ball under the clavicle.

–– Imre L. 21 year old under-worker, lower arm and leg shot.

–– János T. 58 year old hauler, ankle broken from a shot.

–– György A. 16 year old student, left upper arm shot.

–– Gyula B. 26 year old machine technician, crissum shot.

–– István R. 16 year old student, chest and backbone shot. Second and third operation later.

–– Dr. László L. 43 year old medical officer, left arm, right leg, chest, October 27th.

–– Tivadar B. 44 year old, left leg, October 26th.

–– Jenő B. 18 year old student, crissum shot, October 26th.

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–– –– –– –– –– –– –– –– –– –– –– –– ––

Béla Cs. 34 year old, re-operation after 1st operation, October 24th.

István M. 32 year old under-worker, shaft clip, October 30th.

Lajos V. 40 year old film director, backbone injury, November 1st.

Gyula T. 22 year old soldier, heel shot, November 1st.

Wife of Ferenc K. 34 year old independent, chest shaft clip, November 2nd.

Sándor T. 16 year old student, abdominal shot, November 5th.

Botond Sz. 20 year old student, bowel removal, November 5th.

Károly R. 36 year old factory worker, leg shot, immediate amputation, November 1st.

György J. 18 year old student, upper arm shot, November 6th.

N. N. (most likely a Russian soldier) chest shot, November 4th.

N. N. (most likely a Russian soldier) abdominal shot, November 4th.

Szasa P. 18 year old Russian soldier, head and arm shot, November 4th.

Wife of Béla Zs. 44 year old housewife, left limb bull, November 28th.”

They made it to the surgery room. War experience tells that 4-5 times as much could be cared for at the polyclinic. How many died upon arrival, before attended to? How many were taken to the ward for care without surgery? We can only guess A book entitled “Clinic at the line of fire” was published with the story of the Surgery Clinic at Baross street in 1956. There, the flux of casualties was much heavier.

– A walk in the city. A tar-spreader is full of gunshot holes. From afar, its high chimney must have looked like a cannon. Tanks at each bridge-head. Ruins everywhere. Empty shelves behind broken shop-windows. A tipped-over tram. Black flag on one building.

Merry music from an open window. Cold, fog, dampness. Dust-smell.

– Radio broadcast: talk from Gerő..., talk from Mindszenty..., talk from Imre Nagy..., the voice of Kádár..., announcements..., tracts calling to strike..., blurry Free Europe Radio..., good music..., more and more heartbreaking messages..., MUK (we’ll start again in March).

– “Life at the clinic slowly got back to normal, the casualties were attended to. The institution was peaceful, no one was insulted. We listened to Free Europe on the clinic’s only radio, and 44 Th e

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hoped against hope. On November 4th, 1956, all hopes were shattered. A few days later, defection started. If someone asked for a holiday leave in the morning, we went up to him to say goodbye with a handshake. Fourteen doctors left. In the middle of December, Imre Littmann announced one morning that he would take a vacation. We had no doubt of his intentions.

Two days later, he made a phone call from Wien, and asked his adjunct to direct the clinic.

Littmann first went to Hague, with no success. He was not accepted at the Cardiology and Cardiac Surgery Center in London, either. Last he went to Montreal, but did not get a status equal to his title and experiences, so after two years, he returned home, disappointed.

Of course, he did not get his chair back, but received forgiveness in view of his merits. After a few years at common hospitals, he regained his professorship at the Institute of Postgraduate Medical Training, where he stayed until his retirement. A four-month interval ensued in the life of the clinic. Fewer in numbers, the work continued under the direction of adjunct Antal Temesvári, with the exciting question: who will be the new professor?” (quoted from the “green book”).

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“I owe it to Imre Littmann and József Kudász that I became the person that I am” Interview with Professor Endre Pintér, director of the former Lung Surgery Department You wanted to be an obstetric-synecologist, but if I am correct, you were somewhat forced into surgery. How did you feel about that?

I graduated from the Budapest Medical University in 1951, but even before graduation, I was invited to a socalled screening. I stated before the board that I wanted to be an obstetric-synecologist, and had been visiting the obstetrical ward of Janos Hospital for months, and they promised me a job. Yet, the board said: “you will become a surgeon”, which was repeated at the ministry. After a while, I was instructed to report at the Postgraduate Surgery Training Clinic on Városmajor street.

Were you in contact with the army before, or did you just drop in as a civilian?

As it turned out, I was one of the first civilians to participate in the postgraduate training program organized for army surgeons. The clinic’s director was Imre Littmann by then, a civilian, he was directing the program, based on directions given to him by a renown soviet army general. He commended me to talk with Professor Pál Rubányi, a great surgeon of the time, but after a while I got back to Imre Littmann, who was working on getting more civilians to the institution. I can say that I am one of the founders, there are only four of us still alive, one is Ferenc Robicsek, who was Imre Littmann’s favorite.

You mentioned Ferenc Robicsek, who once said that this era was the prime period of Hungarian cardiac surgery. Why did you choose lung surgery after a while?

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According to the rules of the time, we had to spend six months at each department to see what fits us best. In the early 1950’s, we had General Surgery, Ventral Surgery, Vascular Surgery, Lung Surgery, Cardiac Surgery, and Casualty Departments, and I worked in each. Then Ferenc Robicsek invited me to the heart team, which was really an honor.

The team was led by Imre Littmann, it included Antal Temesvári, Ferenc Robicsek and myself as an “apprentice”. So I got to participate in the first Hungarian catheter-based coronary interventions, which I also had a chance to conduct myself, first in 1954, at the invitation of Ferenc Robicsek.

It was a thrilling experience. The first mitral commissurotomy was on September 5th, 1953. I remember that day very well, it was the day of my wedding, and that of Robicsek, too. Upon realizing that the these fell on the same day, Robicsek and myself went to see Professor Littmann, who looked at us and asked: “What? You plan to get married on the day of the first mitral commissurotomy?” So, Robicsek got married, I got married, and we both ran back to the clinic. I was assigned with various preparations. At the time, everyone wanted to learn cardiac surgery, but I did not feel it was that much for me. So I gradually stepped back, and turned towards lung surgery. At the time, it was not a popular field, because there were many suffering from lung disease, and there was a general fear of tuberculosis.

You worked with two outstanding directors of Városmajor, with different ties to each.

What did you learn during this time?

I owe it to Imre Littmann that I learned academic writing. He spent one on one time with us, I learned how to learn, and I also learned how a self-contained surgeon stands on a podium and states what he knows and what he can do. He was a genius, his leadership was strong in organization, discipline, team spirit and all. Then I credit it to József Kudász that I learned to love surgery. I was happy to do it while I could, and trained a substantial group, teaching Kudász-mentality, Kudász-style wherever I could. His hand moved awesome, his operation technique was truly delicate. He had principles, such as “even in the midst of evil, you have to be a man still”, and “you have to grow up and become strong if you want to become a leader”, reciting these over and over again, which at times made us smile, but thinking back, they really stuck with us. I owe it to him to become a seasoned man. Littmann and Kudász had very different personalities, but I owe it to them that I acquired a fame. Both were directors of the Városmajor clinic, and I do not look upon the clinic as my former workplace, I look at it as my home, where I eternally belong.

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“This was the prime period of cardiac surgery, when we had to be cardiologists and inventors at the same time” Interview with Professor Ferenc Robicsek, who was a pioneer of cardiac surgery not only in Városmajor, but in North-Carolina as well You got to work at Városmajor right at the birth of Hungarian cardiac surgery, immediately after graduation, in 1949. You were a student of Professor Imre Littmann, and then became his number one cardiac surgeon colleague. What was it like to work in Városmajor in the prime period of cardiac surgery?

It was a unique time period! We were a team with Professor Littmann and adjunct Antal Temesvári, and did cardiac surgeries without ever seeing anyone do these kinds of interventions before. We did not have a mentor. As far as instruments, we made our own. There was a workshop in the basement of the hospital, where we made our instruments, with the help of our engineer.

For example, I built the first pressure measuring equipment to be used in the heart catheterization laboratory. Some things did not turn out to be ideal, but at the end we had everything we needed.

We did not have a lot of anything, but our accomplishments were not bad, even in international comparison. Around 1949-50, Városmajor and Hungarian cardiac surgery were considered pioneers in Eastern Europe, we had visitors from the Soviet Union, from Bulgaria and from Romania too. There were two notable cardiac surgery centers behind the iron curtain, one in Hradec Kralove, Czechoslovakia, the other in Hungary. First, 48 Th e

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at the Városmajor Clinic, called the Institute of Postgraduate Surgery Training, and then in the University of Pécs, under the direction of Professor Kudász. At first, we did not conduct open heart surgeries at Városmajor, only closed mitral interventions. We did mitral commissurotomy twice a day, five times a week, for about three years, along with closure of the ductus Botalli, Blalock-surgeries, and coarctations.

You had your own department by the age of 28. How did that happen?

Partially, because there was no one before me. Imre Littmann opened a door for me, and said: do it – and I did it. We had a very good team, including Antal Temesvári, who passed away under tragic circumstances, but I think he was one of the best surgeons in Hungary. Another factor that helped my career is that I also learned cardiology. I knew more of cardiology than any surgeons, and more of surgery than any cardiologists. This is an old trick, which I learned from Professor Béla Molnár, who said: “be a good internal medicine doctor, and then you will be a good surgeon!” So, I became a good cardiologist, and thus became a good cardiac surgeon.

From what you are saying about this time period, it seems to me that cardiac surgeons had to be inventors as well.

Yes, inventors and cardiologists. Cardiology wasn’t a separate discipline back then, we did all catheterizations and surgical interventions as well. In a way, our work was easy, because there was no one before us, no competition, no one to get ahead of. This experience helped me a lot when I came to the United States, because Charlotte in North Carolina was also a place with no cardiac surgery. In fact, I can say that I became some kind of a specialist in initiating cardiac surgery, because I was there at the first surgeries in Városmajor with Professor Littmann and Antal Temesvári, I did the first surgery here in Charlotte, and in several Central-American countries, for example in Honduras and in Belize, where I helped establish cardiac surgery. I always had the advantage of being able to look back on my experiences in Hungary, where we lacked both the right instruments, and the technical experience. This was the prime period of Hungarian cardiac surgery.

Your innovation abilities were needed in the United States as well, where you assembled a heart-lung engine in a garage, and performed the first open heart surgery in North Carolina.

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been performed. In general, however, I had the same pioneer spirit here that I had at home. It is a lifetime experience to be first in something.

Was it a hard decision to leave Hungary in 1956?

It wasn’t easy, but it wasn’t hard, either. In 1954, I spent three months in Sweden, at the Karolinska Institute. I couldn’t take my wife along, to make sure I’ll come back. I did not have any Swedish kronas, so I had to prove that one could survive 3 months on milk, bread and butter – this was my “diet” at the surgical lounge. During my time there, I got acquainted with the western way of life, along with political freedom, and this was a decisive factor when I had a chance to emigrate to America with my wife in 1956.

Was it easy to get accepted in the USA, as a doctor coming from behind the iron curtain?

My Hungarian friends often ask me how I could make such a good career in America.

I answer that it is very simple: you just have to work three times as much as your local colleagues, and you won’t have any problems. I did not have any hard time in America for being an emigrant, because America is the home of emigrants. It would be funny if someone said: I don’t like foreigners, while his grandfather came from the Ukraine, his grandmother from England, and had a son who married an Eskimo girl... America is the only country where an emigrant can truly feel at home after a while.

The son of your master, Professor Littmann, worked with you in the United States.

Have you always kept in touch with the Hungarian professionals?

The Hippocratic Oath states that we have to teach the offspring of those who taught us.

Laci Littmann still works at our hospital as an internist. But apart from this, it is true that I never disconnected with Hungary. Even before the end of communism, I used to bring 3-4 Hungarian colleagues here for study trips or congresses. First, my contemporaries and friends, then their pupils, then the pupils’ students. I always kept in touch with my Hungarian colleagues.

You performed 35-36 thousand operations just in the USA. There was a time when you worked day and night. You are a member of various American and International professional societies. You have more than 600 medical and scientific publications.

How did you find the time to dig into Central American Maya culture to publish seven books on that subject?

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I never believe if anyone says “I don’t have time”. If you want to find time for something, you will. In this regard, my advice to the students was: don’t play golf (of course, this is an American example), live close to the hospital to not waste time with travel, and learn to sleep less. I used to sleep 4-5 hours. Another important rule in the profession is to organize your work so that you won’t have to wait on anything. I always went into the surgery room after the patient was fully prepared, and did something else during the preparation. When I spent my free time in Honduras, I operated tuberculosis patients, but they only had enough sheets in the Hospital for one surgery a day. So, I worked between 8 and 10am, and spent the rest of the day among the Maya ruins. One thing led to another, I wrote my first book, than the second, the third…

This period is over with, but I still collect Maya antiques, especially pottery. I caught a collector’s disease. I have a collection of Dutch and Hungarian painters’ artwork, I collect Russian icons, and I also have a collection of airline sick bags, over six hundred pieces. So, my house is like a depot. My wife made a rule that if I bring in anything new, something has to go.

You have a rich professional biography, you initiated cardiac surgery in many countries, which one of your accomplishments are you most proud of?

I retired from the clinic, but I still work 10-12 hours a day. I am emeritus president of the Cardiothoracic and Cardiovascular Surgery Department of the Carolinas Medical Center, vice president of the Carolinas HealthCare System comprising of forty hospitals, surgeon professor of the University of North Carolina, and president of the Haineman Foundation, helping health care services in developing countries. My work in the international assistance program first covered Eastern Europe, but I started working in Central America and in the Caribbean area during the last few decades as well.

Still, what are you most proud of?

My four children and five grandchildren.

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“You do not become a surgeon, you are born to be one.”

(Jozsef Kudasz)

Cardiology hits its stride 4th Surgery Clinic (1957–1975)

Prof. Dr. József Kudász (July 10th, 1904 – April 10th, 1981) He was born in Keresztespüspöki, started his medical studies at the Pázmány Péter University in Budapest, and concluded it in Italy, graduating from the medical university of Bologna. Then he returned home, and started the nostrification process of his diploma. He first earned a living as a cantor, then worked as local doctor in Eger.

Later, he got – first an unpaid – status at the pathology institution of the University of Debrecen.

In 1938, he got a job at the Surgery Clinic directed by professor Huttl, and this was a turning point in his professional career, because here he received surgical training.

He worked alongside Professor Schmidt at the 3rd Surgery Department of Rókus Hospital between 1940-46, in time becoming his adjunct. He was senior surgeon at the Laszlo Hospital in 1946. Between 1947-50, he directed the Children’s Surgery Department of István Hospital. In 1951, he was appointed director of the newly established 2nd Surgery Clinic of Pécs. From 1955, following the death of Professor Sebestény, he was department director in the 3rd Surgery Clinic of the University in Budapest, and director of the Casualty Institution. From 1947, he directed the 4th Surgery Clinic of the 55 Th e

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The wild grape covered building of the clinic in the 1970’s

University. His field of interest was traumatology at first, but from 1947, he turned to cardiac and artery surgery. With Professor Littmann and Professor Árpád Eisert, he was pioneer of Hungarian cardiac surgery. He was both a thoroughly accomplished surgeon and a musician.

During the revolution of 1956, the Postgraduate Surgery Training Clinic was busy with casualties from battles around the nearby Moszkva square. At the end of 1956, Dr. Imre Littmann, Dr. Ferenc Robicsek and other doctors of the clinic fled from Hungary.

Dr. Antal Temesvári adjunct led the clinic from December of 1956 until March 15th, 1957, when the institution received a new name: 4th Surgery Clinic of the Budapest Medical University, and Professor József Kudász was appointed as department director and senior lecturer.

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Dr. András Gömöry, who worked with professor Zoltán Szabó, and initiated heart engine surgeries in Városmajor

There was general surgery, lung surgery, as well as cardiovascular surgery during this time period.

Looking at the 1957-75 period from a cardiac surgery point of view, these were challenging, heroic times. We witnessed the birth of a new discipline: cardiac surgery, and enjoyed its beauty, but also had to deal with all the problems that came along.

Professor with a passionate virtuoso We started open heart surgeries with heart engines constructed with our own hands.

The angiography x-ray was secured on pulling the film over a wooden stand. When the modern diagnostic devices came, it was great to have better angiography pictures and more reliable measuring.

Yes, there were problems, but all who were involved saw the beauty of the profession, and we are still proud of this era. We believe that we had an excellent, brilliant surgeon at the head of the clinic, Professor Kudász.

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Of course, he had his faults, too. He belonged to the old surgical school. If he got angry, he threw out anything through the window, including instruments that then had to be gathered from the yard. If an assistant was not exact in handing him the tools or holding them, a slap on the hand was common place from him. But then, he’d be quick to send for chocolate and charm his colleagues with quick smiles.

His superiors did not like the gentleman-like, well groomed professor, but could not do much against hum. He wasn’t a scientist, but brought along Sándor Juhász-Nagy, who then infused the clinic with science.

The rise of a new profession When cardiac surgery hit the tide, most of closed heart surgeries at the clinic were mitral commissurotomy incisions, but then Professor Swan arrived from the USA, and with the help of the two special plastic “bags”, there were more aorta commissurotomy incisions.

In the field of congenital heart defects, we had closures of the ductus Botalli, Blalock-Taussig shunts, and main vessel stenosis surgeries for the most part. Since we did not have valve prosthesis, or artificial valves back then, we often used lyophilized transplants.

Dr. András Gömöry and Dr. Zoltán Szabó received permission to remove the cardiothoracic aorta section from bodies of people that just passed away. They placed these sections in antibiotic tincture, and transported them to a pharmacy, where they were lyophilized and put into glass tubes, along with hygroscopic mate-

CTA image of a patient operated 50 years ago.

The homograft with sclerosis is easy to see, but it still serves its function, and the patient is well.

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rials. These aorta sections were then used in surgeries. It is notable that – according to follow up research conducted by Professors Zoltán Szabó and László Entz –, three of the patients receiving these in operations are still alive, 50 years later!

In the 1950’s, Professor Kudász also conducted ligation of both external iliac arteries to reduce pressure on the heart. There were about 80 of such surgeries after 1953. Following this intervention, about 38% of the patients got better (as Dr. Tivadar Huttl later reported). In some cases, however, the ligatures had to be released, due to cyanosis in the lower limbs. Similar procedures, e.g. ligitation of the inferior vena cava, were conducted in the institution of Professor Littmann as well.

Treating coronary artery stenosis Several surgical procedures existed for the treatment of coronary artery stenosis. At our clinic, we conducted coronary artery spasm, resection of the preaortic plexus, and novocaine infiltration. In some cases, we triggered sterile inflammation with the application of talcum powder or trypaflavine solution on the cardiac muscles, to prompt vascular adhesion between the muscles and the pericardium. Following Harken’s suggestion, we applied 0,5% phenol, and then, according to Lezius’ instructions, we tied the upper part of the lung to the heart muscles for the same effect.

In two occasions, we tied the peritoneum to the heart muscles. These were substantial interventions, and often we had to drain the exudate.

Both procedures tried to enhance blood flow to the heart muscles, but largely without much success. The Italian Battezzati suggested the ligation of the artery and the vena mammaria by the sternum under rib 2, and Professor Kudász tried this procedure as well, but the results were not too good either. Along with the above mentioned closed heart surgeries, we concluded short, open surgeries as well, although not as many as in the Cardiology Institution.

Since the left heart catheterization technique was not yet known in Hungary, we measured the left ventricular and aortic pressure gradient by inserting a long (Reverdin) needle, connected with a pressure measuring instrument.

The first measuring procedures were carried out with some anxiety, but when we learned that other than a bit of pneumothorax, there were no side effects, we used this technique more freely.

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Ranky adjunct, and then by Professor Kudász himself. General surgery was directed by Dr. József Tóth adjunct, and vascular surgery by Dr. Lajos Soltész adjunct (director of the clinic after the retirement of Kudász). Since Imre Ungár became the director and surgeon of the Korányi Pulmonology Institution, and his colleague, Dr. Pál Keszler (creator of the first Hungarian intratracheal anesthetic machine) went to work at the 3rd Surgery Clinic, Kudász commissioned Dr. László Erdélyi to direct the lung department.

“The future is in the hands of the youth” The clinic in Városmajor was covered by wonderful wild grape at the time. Patients and visitors called Városmajor “the Kudász Clinic”. In 1957, medical student training was initiated, for the most part in the form of field-work, along with a few lectures from professors.

We had six workdays in a week back then, with a long conference and periodical reviews on Saturday mornings, followed by a professorial visit, which lasted until late afternoon.

During the long Saturday morning conferences, we often heard Professor Kudász talk about the development plans in the clinic and at the new university campus, his unique philosophical concepts, the realization of audiovisual medical education (almost a reality now, 50 years later), and professional advice for surgeons. Professor Árpád Péterffy collected his well-known “golden sayings” in a book. Some of these were: “You do not become a surgeon, you are born to be one.”

“You have to learn to see, not just look.”

“Those who fear have no place in the wood.”

“A good surgeon is calm in trouble, … and the best surgeon gets off the worst situations without trouble.”

“The future is in the hands of the youth, so they should be trained right.”

“Talent is not enough to become a surgeon, you have to have ever-increasing diligence and a knowledge of foreign languages. But that’s not enough, either. You have to be a man, too.”

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laboratory built in the previous era, with the help of the X-ray Department (directed by Dr. István Jóna, then by Dr. Gyula Kisvárdi, and later by Dr. Iván Pénztáros).

Just as during the Littmann-era, the interior medicine-cardiologist of the clinic was Professor István Kunos, who listened to the patients’ heart murmur with his stethoscope, and in most cases came up with an exact diagnosis of the heart disease. Sometimes with ECG and chest x-ray. Kunos, the good friend of Professor Kudasz, also played a key role in surgery indications. Later, two young internalists, Dr. Lajos László and Dr. József Pavlik joined him, and relieved the cardiac surgeons in conducting specialized cardiology tests, angiographs and catheterizations. They also took charge of the patients’ internal medicine checkups and treatments at the clinic.

In 1965, Medicina published a book he wrote with Dr. István Kunos, entitled “operable heart diseases”, a comprehensible summary of treatment possibilities of the time.

The book outlined the diagnosis and surgery possibilities of both congenital and acquired heart deformations and diseases, and dealt with open heart surgeries, as well as with techniques in extra-corporeal circulation.

István Kunos had a key role in establishing and organizing the Hungarian Cardiologist Society, and in launching the cardiology conferences in Balatonfüred, where the lectures and discussions centered around the relevant questions of cardiology and cardiac surgery.

In the 1960’s and 1970’s, older and younger cardiologists, cardiac surgeons held monthly lectures in the Weil room of the Doctors’ and Medical Employees’ Trade Union, and had late into the night discussions, highly profitable for all.

Self-designed heart engine In the USA, Gibbon constructed the first heart machine (heart-lung pump) in 1953, providing extra-corporal circulation for longer open heart surgeries. In Hungary, Városmajor needed to prepare for this new surgical technique as well.

In May of 1958, Professor Kudász sent Dr. András Gömöry and Dr. Zoltán Szabó to Brno to learn the technique of using extra-corporal circulation. They were also commissioned to draw a picture of the Mark III. type heart engine, sent to Professor Jan Navratil, director of the local Surgery Clinic from America.

The two-week study trip was highly beneficial, making it possible for the Business Machine Reparing Company in Budapest to construct the Gömöry-Gerber (the latter was the engineer) oxygenator heart machine, similar to Mark III. For over a year, two 61 Th e

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or three, sometimes more doctors – especially Dr. András Gömöry, Dr. Sándor Húsvéti (went to Canada in the early 1970’s), Dr. Zoltán Szabó, Dr. Iván Loblovics, and at times Dr. Sándor Papp and Dr. György Markos – spent their mornings in the human surgery room, and their afternoons and late nights in the animal surgery room of the clinic’s experimental laboratory. With the help of Magda Neumann, they practiced the use of the heart machine, and the technique of open heart surgeries with extra-corporal circulation support. Hundreds of dogs had to be used for the surgeries. Apart from the dog in operation, three or four more dogs were needed for blood support.

The first dog surviving an operation with the self-constructed heart machine

In memory of the perished dogs, Professor Kudász received a beautiful dog statue from a patient working in the Herend Porcelain Manufacture. The statue was placed in front of the clinic.

Hungarian puli in exchange to a machine from overseas The first open surgery with a heart engine in Városmajor, at the Cardiology Institution, took place in 1960, but there was a similar intervention in the year before. The first 16 patients were operated on with the heart engine constructed at Városmajor. Later, we received our first ready-made heart engine from overseas, sent by Béla Köteles, engineer and presbyter, who emigrated to the USA, and had a precision mechanics factory in Cleveland. It was a world-famous PEMCO with an oxygenator, made by Kay and Cross. Professor Kudász sent a puli dog to Mr. Köteles for the valuable present. For the most part, we operated congenital heart deformations. In the 1960’s we had about two open heart surgeries a week. Open cardiac valve operations became more common in the early 1970’s.

In 1961, professor Kudász sent Dr. Zoltán Szabó and Dr. Gömöry to Halle, East Germany, to help organize and conduct the first East-German open heart surgery. In July of 2012, we received a kind letter and a DVD from Professor Neef, about the jubilee 62 Th e

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One of the first open-chest surgeries using the Gömöry-Gerber heart pump in 1960

symposium of the Halle University. Dr. András Gömöry spent about a year and a half at the Kanton Spital cardiac surgery in Zurich. He and Professor Kudász had a strained relationship to start with, and it became even worse after his return, so he applied for and received a job at the University of Debrecen in 1972.

Professor Kudász strongly emphasized the training of young surgeons. He required them to spend at least a month or two in the laboratory and at the x-ray department, and attend each necrotomy. It was also a “Kudász-requirement” that the doctors had to follow up on the recovery of their surgery patients.

He was convinced that the Hungarian surgeons had nothing to be ashamed of. Keeping up with scientific advancements was important to him, he encouraged the reading of periodicals, along with study trips, usually within the country, as it was rare to be allowed to travel abroad.

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Picture with the medical staff after the 100th open heart surgery

Child cardiac surgery care in Városmajor Apart from general, cardiac and vascular surgeries, Professor Kudász conducted lung surgeries as well. During the late 1950’s, in the early 1960’s, he (with the help of dr.

László Ranky) operated two newborn babies with oesophageal atresia, one of which was the first successful operation of this kind in Hungary.

There was a Children’s Ward with 20 beds at the Városmajor Clinic, directed by dr.

Gömöry, until the 2nd Children’s Clinic on Tűzoltó street (directed by dr. Lajos Böröcz, and then by dr. Károly Lozsady), and the children’s section of the Cardiology Institution started cardiac surgeries of infants and children in greater numbers.

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Careers at home and abroad Several Kudász-students and colleagues were appointed to leadership positions later on, both at home and abroad. One of the best known, Dr. Ferenc Robicsek, used to direct the Cardiac Surgery Department, as well as the old experiential laboratory (the so-called animal surgery room). Apart from initiating new cardiac surgery procedures (experimented on animals first), he also worked on the development and construction of new instruments (for example, the Robicsek-Géczy manometer, etc.). Dr. Ferenc Robicsek left for the United States after 1956, and in time became the director of a large cardiothoracic and cardiac surgery institution in Charlotte.

In 1988, Imre Haynal University awarded him with an honorary doctorate degree.

Professor Robicsek was a frequent guest lecturer at cardiac surgery conferences in Hungary, and several of his colleagues were able to visit him in the States.

Dr. Péter Gloviczki moved to the U.S., to the famous Mayo Institution in Rochester in the 1980’s, and became perhaps the most widely known vascular surgeon from Városmajor. He is now chairman of the Society for Vascular Surgery (SVS), and has helped a lot in graduate vascular surgery training.

Dr. András Gömöry was appointed vice president of the cardiothoracic surgery clinic of the university in Debrecen. Professor Attila Nemes became president of the Városmajor Clinic in 1992, and vice president of the Semmelweis University. Dr. Csaba Dzsinich came to the clinic as a general surgeon in 1969, and then worked at the Vascular Surgery Department. In 1994, he became a professor, and also gained international recognition in his profession. In 2000, he was appointed president of the European Society of Cardiology. Dr. Iván Loblovics came to work with Professor Littmann at the cardiac surgery department, who was directing it after his return. Loblovics later became senior surgeon at the hospital in Szombathely, and then moved to Germany.

The first pacemaker The first pacemaker implantation took place in 1963 at the clinic. The patient received an Elektrodyne VVI pacemaker. (During the previous year, there was a pacemaker implantation at the Cardiology Institution as well.) The first Hungarian pacemaker ready for implantation was constructed by Dr. Zoltán Szabó and László Bocskay electro-tech65 Th e

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nician in 1967. The device had a 5 mercury cell battery, and was covered with epoxy resin and acrylate. With an M 5816-type electrode, it worked for 18 months and a half (devices worked for about 20-22 months at the time).

Dr. Zoltán Szabó wrote his candidate thesis on pacemaker-therapy issues.

Professor István Kunos retired in 1970. Dr. Ferenc Solti was appointed the leading cardiologist-internist of the 4th Surgery Clinic. He had been working at the 1st Internal Medicine Clinic, led by Professor Rusznyák, and The first implanted Hungarian pacemaker, then by Professor Imre Magyar, since 1947. By constructed by Szabó-Bocskai (1967) then, Solti was a renown expert in the experimental research and treatment of arrhythmia.

Dr. Ferenc Solti and Dr. Zoltán Szabó co-authored several books on pacemakers and arrhythmia. In the 1970’s, Solti and the young Dr. Ferenc Rényi-Vámos, as well as Dr. Zoltán Szabó was influential in turning the Városmajor Clinic a base institution for domestic pacemaker-care.

Dr. Ferenc Rényi-Vámos arrived at the clinic in 1966, and after his surgeon specialist exam, spent a bit more than a year at the Surgery Department of the Wien University, as well as in a large hospital, dealing with medication and pacemaker treatment of arrhythmia.

Dr. Solti became president of the Pacemaker Work Group, established in 1975, of the Hungarian Cardiologist Society, with Dr. Rényi-Vámos as clerk, drafting the first Hungarian pacemaker register. Dr. Ferenc Rényi-Vámos died at a rather early age, ending the promising carrier of an excellent cardiac surgeon in Városmajor.

Later, in the 1990’s, Dr. Béla Merkely and his colleagues played a vital role in the development of clinical electrophysiology.

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Artificial cardiac valve, even from pork Dr. Tihamér Lónyai, returning from a study trip to America in 1963, conducted the first Hungarian artificial cardiac valve implantation at the Cardiology Institution. The first results with artificial cardiac valves were not favorable at the Városmajor Clinic, so we turned towards biologic cardiac valve implants. Pork aortic valves (xenografts), fixed in formalin, later in glutaraldehyde, were implanted in the mitral stenosis. We learned the procedure in Szeged, from Gábor Kovács, who learned it from Ionescu in Leeds.

Dr. Zoltán Szabó, Dr. Elek Bodor and Dr. Ferenc Rényi-Vámos used to go out to the slaughter-house in Pest and bring pork hearts in buckets, often preparing and sewing valves on frames they got from Ionescu. Surgery mortality was high to start with. Later, it got better with factory-made biological and artificial valves, especially when modern cardioplegia came along.

In 1972, Professor Bodnár in the Institute of Postgraduate Medical Training, and then Dr. Attila Árvay in the Cardiology Institution, conducted the first successful coronary bypass surgeries. Later on, Dr. László Szlávy and our new hemodynamics staff, Dr. Elemér Czakó and Dr. László Szatmáry conducted an ever increasing number of coronary catheterizations, and the cardiac surgeons conducted more and more direct coronary artery bypass surgeries.

The importance of anaesthesia Professor Kudász had an excellent anesthesiologist in the clinic in Pécs, Dr. Lajos Nagy, who was originally a surgeon, and re-trained himself as an autodidact. In Városmajor, after Palosek left, Doctor László Lencz, János Lauth, Andor Kulcsár, József Vécsey, and occasionally Dr. Iván Loblovics and Dr. Katalin Szánthó did anesthesiology. Towards the end of the Kudász-era, Dr. Imre Kalmár and Dr. Ida Matkó, as well as their younger colleagues, such as Dr. Éva Pongó, Dr. Gabriella Nagy, Dr. Mária Windisch, Dr. Katalin Széphelyi, Dr. György Nyikos and Dr. Eszter Turbó, followed in their footsteps.

Developments in cardiovascular anesthesiology made a great difference for the patients.

The clinic was fortunate to get a few anesthetic machines and respirator machines, but we barely had modern hand-held instruments. We cleaned and sterilized the oxygenator tubes ourselves, and made external triggers of soap boxes and used pacemakers. Most of our clothes smelled like dogs, from the time spent in the experiential laboratory.

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Back then, we anxiously waited for passports for months, in order to be able to go abroad for conferences or study trips. Much of our world was closed, firsthand experiences of other societies, along with their scientific knowledge, were limited and monitored.

We also had financial problems, the cost of a surgery was more than what we received for it. It wasn’t until the early 70’s that university institutions conducting cardiac, pacemaker and artificial valve surgeries received a separate cardiac surgery fund.

Friendships with nuns and sisters, forged in abroad study trips, also helped a lot. We had a good relationship with the Cardiac Surgery Department in Munich, where Dr. Zoltán Szabó was able to spend several months in 1964 and in 1974. The clinic received much help from them, they sent us enough new tools, thread and suction tubes to last all year.

Changes in general surgery Of course, we not only had cardiac surgery, but also general surgery at the clinic. The smaller general surgery department was first directed by Dr. Miklós Róth. Dr. György Vass worked alongside Dr. Alajos Padányi for a while, before returning to the Vascular Surgery and the Lung Surgery Department. Dr. József Lengyel also worked here for a while, before emigrating to West Germany, where he became an anesthesiologist. In addition, young doctors preparing for their specialty board exam also worked there on internships, so most young surgeons at the clinic spent some time there.

Professor Kudász, who was an excellent general surgeon as well, conducted almost all kinds of surgeries known at the time. The General Surgery Department was important in medical training and specialty board exams as well. Then Professor Kudász brought an excellent general surgeon from another university surgery clinic, Dr. Sándor Drobni, virtuoso in ventral surgery. He was later appointed senior surgeon at the László Hospital. Later on, medical training underwent certain changes, and we did not participate as extensively in education. Thus, the General Surgery Department gradually lost its importance.

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The development of lung surgery Following the 1957 changes mentioned before, Kudász commissioned Dr. László Erdélyi with directing the Lung Surgery Department. At different times, Dr. Alajos Padányi, Dr. Endre Pintér, Dr. Iván Loblovics, and then Dr. Attila Nemes, Dr. István Besznyák, Dr. Ádám Balogh, Dr. László Tóth, Dr. Miklós Sebestény, Dr. Zoltán Sulyok and Dr. István Mogán worked there for substantial periods.

The country emerged from the tuberculosis epidemic, the first medications came out (Streptomycin, INH, etc.), and the number of lung surgeries was on the rise as well.

New types of sewing machines appeared, of better quality. In addition to thoracoplasty surgeries, full lung removal (pneumonectomy) was also conducted.

Of course, complications multiplied as well, raising surgery mortality rates. Open chest surgeries required central ventilation and intensive care units. At the ground floor of the clinic, a small room was used for bronchoscopy testing.

With better monitoring, more chest diseases were recognized and the scope of surgery became wider. The late 1960’s brought along the surgical treatment of several types of lung carcinomas, leading to the development of pulmonary oncology, and oncology surgery.

At the clinic, the Lung Surgery Department underwent several changes. Dr. László Erdélyi was appointed director of the Surgery Department of the Home Affairs Hospital, at the time located on Gorkij alley. Dr. Endre Pintér, who used to work at the Lung Surgery Department of the Vogelsand Clinic of Magdeburg (in 1964-65), came to replace him at the clinic.

A few years later, from 1970, he became the senior doctor of the General and Lung Surgery Department of János Hospital, gained distinguished professorship in 1989, and was appointed director of the Surgery Department of St. Margit Hospital between 197894. (Later, the beloved Professor Kudász passed away in his department.)

At the clinic, Dr. István Besznyák replaced Professor Pintér, with vigor and wide-range publication. In the early 60’s, Dr. Besznyák spent a year at the Surgery Department of Harvard University, which turned out to be very useful for his carrier. In 1977, he left for the Countrywide Oncology Institution, where he directed the Surgery Department.

In 1984, he became the institution’s director, and received a Széchenyi Award in 2002.

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Vascular surgery, the other stronghold Along with cardiac surgery, vascular surgery was another stronghold at Városmajor. It was initiated by Dr. Lajos Soltész, adjunct, during the Littmann-era, and became the largest department of its kind in Eastern-Central Europe in the 70’s and 80’s. Kudász reinforced Soltész’s leadership. His closest associate was Dr. Imre Szabó. Dr. György Vas also worked there as a vascular surgeon, until he became the senior physician of the Tétényi street Hospital.

When Professor Kudász was appointed president of the clinic, the Vascular Surgery Department received excellent staff members, including Dr. Sándor Papp, Dr. Attila Nemes, and then Doctors György Acsady, Csaba Dzsinich, István Mogán, József Frank, Lajos Molnár and Eberhard Krause. Several young doctors worked at the Vascular Surgery Department, as well, surgeons from all over Hungary came to study the procedures.

Today’s “senior” vascular surgeons were the younger generation back then. Dr. Attila Nemes examined tissue connecting techniques, and wrote his candidacy presentation on this subject. He also published several angiology and vascular surgery books, and became director of the clinic after Professor Zoltán Szabó. Dr. György Acsady was a Hungarian pioneer of artery surgery, and led the clinic following Attila Nemes. Dr. Csaba Dzsinich became an expert of vascular surgery solutions for artery renal stenosis, as well as for special cases of aortic dissection. He is now a senior vascular surgeon in the Army Hospital, and Dr. István Mogán became senior physician of the Vascular Surgery Department in the St. Imre Hospital. They all played a leading role in the development of vascular surgery in Hungary.

When Professor Kudász retired, the 4th Surgery Clinic became a National Institute of Vascular Surgery, under the leadership of Professor Lajos Soltész, but the new de­ partment director encouraged the development of cardiac surgery, led by Dr. Zoltán Szabó.

The end of a 20 year long era The Kudász-era did not end in 1975, with his retirement. The professor was 70 years old, but continued to work at the clinic – then led by Professor Soltész. He used the old room of Dr. István Kunos, sharing it with Dr. Zoltán Szabó as time passed. He sold his house in Városmajor, but bought a nearby flat.

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The medical staff of the clinic in 1975, at the retirement of Professor Kudász

At the clinic, he monitored his former patients, and even took some new ones, o­ ccasionally conducting a few surgeries. Then came the last one. He was to operate on a primum type atrial septal defect. Dr. Szabó assisted his old boss, his idol, the brilliant surgeon, and noticed that something was amiss. The professor got nervous, and said: “I have to go to an appointment, finish it up!”. He never came to operate again. Then we learned that he was ailing already.

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Professions in time History of the Experimental Laboratory (1966–2009) The forerunner of the experimental laboratory, the experimental surgery room operated in the small building in the yard of the clinic, set up by Professor Littmann in 1952, from the staff quarters of the old János Sanatorium. Several surgery technique experiments, instrument innovations, and therapeutic monitoring took place here, conducted

by Dr. Ferenc Robicsek, and then by Dr. András Gömöry, Dr. Sándor Húsvéti and by Zoltán Szabó.

However, the experimental laboratory, its professional character and spirit was attached to the name of Professor Sándor Juhász-Nagy for decades. He was an exceptional cardiac and circulation researcher with original views, extended scientific knowledge, the vein of a great teacher.

The building of the experimental surgery room around 1920

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The walk of life for an exceptional researcher Sándor Juhász-Nagy (1933-2007) was born in the city of Debrecen, to an old Calvinist family on both sides. His protestant faith led to an inner discipline, which never left him, and had an influence on all he did.

After completing the Calvinist Boarding School of Debrecen, he graduated from the Medical University of Debrecen. He was the first to receive a “Sub auspiciis Rei Publicae”, a golden ring distinction, for excellency in all high-school and university exams.

During his sophomore year, he joined a team, led by Dr. István Went, at the Department of Physiology, which started his career as a researcher. Working with Dr. Mátyás Szentiványi, he proved the arteries to be rather independent of the heart muscles in the sympathetic nervous system. This is now in the textbooks, but was contrary to what the profession believed in the 1960’s. Following the death of Professor István Went (1963), the institution lost its democratic spirit, and they both left their alma mater.

Dr. Sándor Juhász-Nagy looked for new possibilities, and came to Professor József Kudász in 1966, then director of the 4th Surgery Clinic, who trusted him with the establishment of a separate research department. From then on, he worked as director of the experimental laboratory for four decades, in search of the mysteries of the heart and of the circulatory system.

The young Dr. Sándor Juhász-Nagy (on the left), and his friend, Dr. Mátyás Szentiványi

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His field of interest was extremely wide, from the basic physiology of the heart, to clinical problems. He published over 250 articles (most of it in international journals), along with 29 books and book chapters on coronary circulation, cardiovascular reflexes, adrenergic and purinergic receptors, metabolic blood flow regulation, surgical heart muscle protection, cardiothermography, cardiac electrophysiology, peptidergic arterial regulation, and heart fluid compartments. With his dissertation, entitled “Coronary reflex”, he gained a candidate’s degree in 1972, followed by DSc in 1977, and university professorship in 1982.

He was an exceptional researcher, not only for his depth of knowledge, but also for his unique perspective and ability to synthesize the details and recognize connections. As a teacher, he tried to pass this on to his students and colleagues. Whoever had a chance to work with him, or just listen to his lectures and ideas, will never forget the experience.

Under his leadership, and with his co-operation, 24 candidacy and PhD dissertations, and 5 DSc dissertations were born. In addition, he participated in the PhD and DSc teaching process as an opponent and as a reviewer, producing dictum so full of valuable insight, that some people even came to collect them.

He worked as member of the Semmelweis University’s TDK Council (1988-2006) and Doctoral Council (1993-2006), the joint cardiovascular board of the Hungarian Academy of Sciences and the Medical Ministry (1985-1991), and as an advisory member of the Medical Sciences Department of the Hungarian Academy of Sciences (1991-2006). He was president of the Department of Physiology in the Hungarian Scientific Research Fund (1991-1996), and then of the advisory board of Széchenyi Professorial Scholarship (1996-2000), always standing for self-determination and high professional values.

Professor Sándor Juhász-Nagy received several honors, including the Szent-Györgyi Albert Award (1994), the Széchenyi Award (1999), the Semmelweis Medallion (2000), the Medallion from the President of the Republic Award (2003), and “Laureatus Academiae” title from the Hungarian Academy of Sciences (2004). After his retirement (2003), he worked as emeritus professor at our university until his death. He passed away at home, surrounded by his loved ones, on January 8th, 2007.

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A relationship built on mutual respect Dr. Sándor Juhász-Nagy, the young and ambitious research doctor took the experimental surgery room in 1966, and turned it into a complex circulatory-physiology laboratory.

Along with ongoing research started in Debrecen, he also worked with Professor Kudász and interested colleagues from the clinic on cardiac (and later, vascular) surgery problems.

Even though the laboratory’s outfit was rather poor and outdated, his early work yielded several important results – publicized in about 30 articles of domestic (Weekly Medical, Acta Physiologica Hungarica, Acta Medica Hungarica) and international (Arch Int Pharmacodyn Th er, Experientia, Journal of Cardiovascular Surgery, Japanese Heart Journal, Basic Research in Cardiology) journals. Some of his co-editors included Dr. Mátyás Szentiványi, Dr. Lóránd Debreczeni, Dr. Ádám Balogh, Dr. Lóránd Bertók, György Grósz, Dr. József Kudász, Dr. György Kunos, and Dr. Ferenc Solti.

The chart on the other page outlines some of the major accomplishments of this era. It was an attachment to a letter sent to Ferenc Antoni, president of the university, asking for his support on modernizing the experimental laboratory, refurbishing its tools, and enlarging its staff.

In 1974, the laboratory staff consisted of the director, one attendant, one scrub nurse, one animal attendant, one cleaner and a part-time technician.

He was asking for two more assistants, which he did not get, but in time the attendant and the scrub nurse The attachment of the letter sent to university president Ferenc Antoni 75 Th e

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learned all the necessary knowledge in surgery-preparation, measurement technique, surgery room, laboratory and nursing, which they then passed on to new colleagues as they came along.

Inosine-research Dr. Sándor Juhász-Nagy went on a study trip in 1976-77, and spent a year as visiting researcher at the Pharmacology Institution of the University of Pennsylvania, at the invitation of Domingo Aviado. Here, he started researching adenosine metabolism.

In the meantime, at the Városmajor laboratory, Dr. Ferenc Solti and Dr. Attila Nemes researched arrhythmia and coronary hypoxia. When Dr. Sándor Juhász-Nagy returned, several surgeon colleagues from Városmajor joined him at the laboratory, and later became excellent cardiac and vascular surgery professors: Dr. Ádám Balogh, Dr. Elek Bodor and Dr. Miklós Sebestyén, Dr. Ferenc Rényi-Vámos, Dr. Sándor Papp and Dr. Péter Gloviczki. Their research is well documented in the experiential animal log, the “large green book”, starting from January 2nd, 1969, to this day.

The research starting in Pennsylvania continued here from 1978. Dr. Sándor JuhászNagy worked together with the newly arrived, young and open-minded cardiac surgeon, Dr. Lajos Papp. They examined the complex, inotropic and cardioprotective effects of inosine on the heart muscles and on blood flow. Even though long years of research and several publications in domestic and international journals proved the highly beneficial effects of inosine, the pharmaceutic companies were not much interested in producing medicine with it (for a while, it was in circulation as Trophycardil in France). After 20 years, however, the new generation of researchers and surgeons came back to this question, reflected in the works of Dr. Gábor Szabó, Dr. Csaba Szabó, Dr. Gábor Veres and Dr. Tamás Radovits.

“A real, open research workshop” Under the direction of Professor Sándor Juhász-Nagy, the experimental laboratory became a lively, high-morale and open research workshop, where students worked along with younger and older colleagues in several fields. Dr. Péter Sotonyi researched cardiac effects of the k-strofantozyd, Dr. Lajos Papp and Dr. Endre Moravcsik researched car76 Th e

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dioplegia methods, Dr. Gábor Pogátsa researched the connection between tissue edema and stiff heart, Dr. Attila Nemes researched revascularization possibilities, Dr. György Rablóczky researched dopaminergic heart- and coronary effects, and Dr. Lóránd Bertók researched natural immunity processes with us.

Later, as visiting researchers, until establishing their own research place and laboratory, we had Professors Gábor Pogátsa and Zoltán Nagy. György Grósz developed his first hemodynamic tools and measuring probes here.

Thermal imaging in cardiology Computerized thermal imaging came into use in monitoring the blood flow and metabolism of the heart muscles in the early 1980’s, with Dr. Sándor Juhász-Nagy and Dr. Lajos Papp working out its methodology and quantification in this laboratory. They were first to demonstrate that with given contextual factors, the infrared radiation of an

Dr. Lóránd Bertók, Dr. Sándor Juhász-Nagy, Dr. Violetta Kékesi and Dr. György Rablóczky at a conference of the Hungarian Physiology Association

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open heart is proportional to its myocardial blood flow. The recognition and mathematization of this simple correspondence opened up new research directions. The method was unique, because it was very exact in monitoring blood flow, both the spatial and the diachornic dimensions. Further research and then several human heart operations proved its effectiveness.

Renovation, modernization, new research directions In the meantime, great changes took place in the life of the laboratory. Thanks to Professor Zoltán Szabó, the experimental laboratory was renovated and modernized, while the Department of Cardiovascular Surgery received a new surgery block. The renovation took less than a year, and we received a clean, well equipped, modern building as laboratory block in 1983. During the renovation, we worked in the Medicine Research Institution,

Experimental Laboratory, 1983

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at the laboratory of Dr. György Rablochky, director of the Pharmacology Department.

They also experimented on animals, but mainly on cats.

During the late 1980’s, the laboratory started experiments in a new field, looking for possibilities in coronary venous retroperfusion. It was during this time, that Werner Mohl established the methodology of blood retroperfusion and intermittent occlusion with reference to humans. As it often happens, the experimental results were good, but it did not fully carry over to application on patients. Still, retrograde cardioplegia meant a large forward step, heart muscle protection on both sides, the coronary arteries and the venous system, was more efficient than the same on one side only, because the solution reached areas behind strictured or blocked vein sections. Retrograde cardioplegia is still in use today.

In the research laboratory, we outlined, as fully as possible, the effects of sinus coronarius occlusion – from cardiovascular reflexes, through catecholamine responses, to the optimal level of influencing blood flow to the heart muscles. The main conclusion was that blood surplus for rinsing is most effective when combined with adenine nucleosides.

Later, Dr. Violetta Kékesi wrote his candidacy dissertation on this subject.

Preparations for the first heart transplantation In 1989, at the experimental laboratory, Professors Zoltán Szabó and Elek Bodor were preparing for a great event in Hungarian cardiac surgery, the first heart transplantation.

They had been on several study trips, experimenting with the operation, getting used to the tools, developing the techniques. They practiced on animals, and we were all excited on the transplantation days: will the implanted heart start after defibrillation, will it have enough strength to support circulation, will the seams hold, etc. Animal experiments went on for about a year before the first real, human heart transplantation.

Accredited doctoral program The 1990’s brought several new things, both in research fields and in training forms. New research fields included endogenous opioid peptides in myocardial regulation, agents in the periocardial fluid, as well as therapy options with electrophysiology. Candidacy was replaced with PhD training.

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Professor Sándor Juhász-Nagy is explaining something, the student (on the right) is Gyöngyi Hargita, the colleague is Dr. Violetta Kékesi.

Our interdisciplinary doctoral program, composed by Professor Sándor Juhász-Nagy, was among the first to receive accreditation (in 1993), the first sub-program leaders were Dr. Sándor Juhász-Nagy, Dr. Lajos Papp, Dr. Miklós Tóth, Dr. Péter Sotonyi Sen., Dr. István Dobi, Dr. János Hamar, Dr. Kinga Karlinger and Dr. Violetta Kékesi. A bit later, in 2001, Dr. Béla Merkely, Dr. László Entz, Dr. Ferenc Horkay, Dr. Gábor Balázs Szabó and Dr. Viktor Bérczi joined the program with experimental and human research project plans. The third wave came around 2006-2007, with more to join, and since 2010, our own former PhD students initiate new projects in the program.

The sub-program leaders and the project managers kept bringing new students, working hard, experimenting and seeing success in the above mentioned fields. Our first PhD student, Dr. István Szokodi (now research director adjunct professor at the PTE Cardiotherapy Institution) continued the research Dr. Miklós Tóth started with natriuretic peptide and endothelin, within the co-operative framework Dr. Mikoós Tóth set up with the University of Oulu in Finland. As time passed, research was extended to inotropic 80 Th e

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Dr. Béla Merkely and Dr. Sándor Juhász-Nagy in the research laboratory, on the professor’s 70th birthday

peptide, adrenomedullin and apelin, and their subcellular mechanism. The results of Dr. István Szokodi are being published in journals of the highest qualification.

This era brought the discovery that apart from blood plasma, the pericardial fluid includes other materials in large concentration, such as andenosine, atrial natriuretic peptide (ANP) and endothelin 1.

Recognizing the pericardial accumulation of agents originating from the heart was important for at least two reasons. First, it is very likely that they originate from cardiac interstitial fluid, and show the concentration of a certain agent much better than the plasma, plus most endogenous cardioactive materials exert their influence in the interstitium. Second, these highly concentrated pericardial materials might effect cardiac and coronary functions.

The natriuretic peptide level of the pericardial fluid in humans was researched in Hungary by Dr. Ferenc Horkay and his PhD student, Dr. Pál Soós, who expanded the mathematical model established by Colin P. Rose and modified by Keith Kroll, on adenosine in intracellular, intravascular, interstitial and pericardial fluid.

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Professor Sándor Juhász-Nagy with students

Results clearly showed that mathematical approaches are not sufficient, in vivo tests were also needed.

In later years, Andrea Nagy, Ildikó Toma, Balázs Sax, and other PhD students continued, with success, the research of peptidergic regulation, and effects from the pericardial space.

New directions in experimental arrhythmia research At the same time, experimental arrhythmia research took a new direction and became intensified, due to modernization in cardiac care. In 1993, a young assistant lecturer, Dr. Béla Merkely, took up experimental research in this field. His enthusiasm and energy, 82 Th e

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coupled with faith in future results and joy in accomplishments, has been contagious, drawing many young colleagues and students into the work.

Under his direction, experimental cardiology research followed two main directions: in vivo testing of new electrophysiology methods on heavy ventricular arrhythmia mechanisms, and the development and testing of therapeutic methods. Endothelin-1 played an important role in the testing, due to its arrhythmogenic nature (tachycardia), discovered in our laboratory (by Dr. Miklós Tóth). Recognizing that an excellent arrhythmia model can be built on this effect, Dr. Béla Merkely used this model in several tests, and so did his PhD students and future colleagues, such as Dr. László Gellér, Dr. Endre Zima, Dr. Orsolya Kiss, Dr. Hajnalka Vágó, Dr. Andrea Szűcs, and Dr. Szabolcs Szilágyi. They all wrote their PhD thesis, at least partially, on this subject. Dr. László Gellér is now associate professor, director of the Electrophysiology Department of the Városmajor Heart Center. Dr. Endre Zima, senior lecturer, directs the Intensive Cardiology Unit.

Naturally, and along with other PhD students (Dr. Attila Róka, Dr. Valentina Kutyifa, Dr. Pál Haurovich Horvát, Dr. Gábor Szűcs, Dr. Gabriella Veress, and Dr. Edit Dósa), the young researchers participated in clinical testing as well.

Instrument research experiments were also conducted, including the usage and development of monophasic action potential (MAP) electrodes, the geometrical and material development of defibrillator-pacemakers, the extension of resynchronization therapy, as well as the temperature-optimization of new ablation catheters and the testing of their coating. With international cooperation, Professors Béla Merkely and Zoltán Szabó developed the implantable cardioverter defibrillator (ICD) in this laboratory.

In 2003, the Cardiovascular Center, directed by Professor Béla Merkely, was established with members of the experimental and clinical cardiology research team, and in 2007, they became the main body of the Independent Cardiology Center – Cardiology University Department.

The peptidergic research and the electrophysiology tests yielded 12 PhD dissertations, as well as several DSc dissertations, written by Dr. Ferenc Horkay (2001), Dr. Miklós Tóth (2002) and Dr. Béla Merkely (2006).

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The GLP qualification After pacemaker and ICD electrode development projects with international partners, the laboratory set out to acquire the Good Laboratory Practice (GLP) qualification to become an accredited test location and enhance further cooperation. We regulated our management from daily activities, through administration, to our own inspection system.

We received the qualification right away, and the system has been working well. Of course, we keep updating it, under the supervision of the National Institute of Pharmacy.

Along with peptidergic modulation and arrhythmia research, work was going on in other fields as well. Dr. Levente Fazekas, who used to work for years with Professor Lajos Papp at the Cardiotherapy Clinic in Pécs, conducted research on endothelin and adenine interaction and mechanisms. He is now an adjunct at the Városmajor Cardiac Surgery University Department.

Youngsters in the laboratory Former PhD student, Dr. Tamás Szabó continued the thermographic testing of human myocardial blood flow under surgical revascularization. He now works at the Anesthesiology Institute of the Ralph H. Johnson VA Medical Center in Charleston. Dr. Terézia Andrási, a former student of professor Sándor Juhász-Nagy, continued the research of mesenteric vein activity modifications. She now works as a young and talented surgeon at the Cardiovascular and Lung Surgery Institution of the Johannes Gutenberg University in Mainz. She was the first PhD student to learn and research with another excellent supervisor of the program, Professor Gábor Szabó, working at the Cardiac Surgery Department of the Heidelberg University. With a great team of PhD students: Dr. Tamás Radovits, Dr. Gábor Veres, Dr. Enikő Barnucz, and Dr. Kristóf Hirschbert (student of Professor László Entz as well), he conducted extensive research on ischemia.

They were highly successful in developing new preservatives to be added to the tissue conservation liquid, reducing the impact of negative effects (cold, pH-shift, oxidative impairment) on the donor heart, providing for a longer time-span before implantation.

Thus, more donor hearts can be available from a wider range of geographical locations.

From this team, Dr. Tamás Radovits returned, with his characteristic purposefulness, consistency, and wide range of experience, especially with in vivo small animal experiments. He came to the experimental laboratory in 2009, at the invitation of Professor Béla 84 Th e

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Merkely, and now has his own group of PhD (Dr. Attila Oláh, Dr. Csaba Mátyás) and other students, carrying research projects in diabetic cardiomyopathy, aging-associated cardiovascular dysfunction, and athletic heart syndrome.

Katalin Turi TDK, a former PhD student tested a former theory of professor Sándor Juhász-Nagy, the double vascular effects of Ca-ions, with the help of Ca-inofor molecules on coronary arteries, with in vivo and in vitro methodology. The latter “enterprise”, the methodology, application and measurement (with the help of György Nádasy) of isolated coronary resistance tested on veins, led to success, and was finally able to demonstrate the reaction caused by Ca-ionofor on endotel-denudated veins.

“It was special to be in his company” The list could go on, because the research workshop of Professor Sándor Juhász-Nagy was open to all. If someone approached him with a less developed or false idea, he did not terminate the communication, but gave advice to point out the right way to go. He was a great co-operator, and always enjoyed to “touch base” with people. It was special to be in his company. Talking to him initiated feelings of reverence, curiosity and love.

He was naturally kind, genuine and well accomplished, but there were two things he immediately lashed out on: conceitedness and lying.

While the world of Professor Sándor JuhászNagy bloomed, science has changed a great deal out in the world. The era of discoveries was replaced with the era of “postmodernism”, where science digs deep, but Professor Sándor Juhász-Nagy, 2006 does not synthesize, looks at (The picture is taken from the “Apáink jönnek velünk szembe” [Our fathers coming details and works with great towards us] movie series, the part on Sándor Juhász-Nagy. Editor-reporter: Ferenc Herzka.)

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amounts of data, but interprets less, and has no time for meditation, for the often timeconsuming search of correspondences. Most research follows trends, and looses its originality. It requires expensive tools and materials, and it is supported on a consortial basis.

In its aim to discover, the “quantity leads to quality” type of thinking gathers, stores, moves and publishes a lot of research material.

He was working on helping others get ahead until the very end of his life. During his last year, he saw to it that all PhD dissertations in process get turned in and defended. He asked his former student, now DSc Professor, Béla Merkely, who stayed at Városmajor, to take over the doctoral program. He entrusted the research laboratory and the Studia Physiologica short monographs to Dr. Violetta Kékesi. He faced his slowly approaching death with dignity, showing an example to all.

One of his students, Lajos Papp, writes the following about Sándor Juhász-Nagy in a work entitled “The Master”: “The Master teaches you not to expect anything back from what you give, for it is not a loan, but a talent, which you have to multiply and pass it on.

You have to be diligent, not indebted.

The Master never accepts gratitude, because the Master does not need it.

The Master expects the same we read in the parable: – If you received five talents, double it, and you are a good steward.

My Master is a true sculptor of men. He only takes enough off to help the real essence appear.”

(Lajos Papp, 2006) Passing and birth are sisters. For all that passes away is unrepeatable. All that is born carries something new.

Professor Béla Merkely, a Sándor Juhász-Nagy student, stood at the bedside on that January morning. Then he turned his head away…

Revitalization and rejuvenation At his first chance, after the organization of patient care, and the renewal of cardiology training, about two years after the death of Professor Sándor Juhász-Nagy, he undertook a large-scale development of the experimental laboratory. In the field of research program 86 Th e

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The new laboratory, 2009

expansion, this was not just a fix up the surface kind of thing, but a through revitalization and rejuvenation.

The old laboratory received a new outlook and new instruments. A new floor was added, making it possible to separate the surgery rooms from the study and socializing areas. New tools and appliances included a modern X-ray machine, a Leycom pressurevolume analysis instrument, and a new heart engine for hemodinamic and electrophysiological animal experiments.

In the renovated building, he established in vivo and in vitro small animal laboratories, and today there is a genetic laboratory as well. New members joined the research team, Professor Merkely invited Dr. Tamás Radovits (former student of Dr. Gábor Balázs Szabó). The excellent young researcher brought new experimental models and methods, advancing ongoing research on cardiovascular in vivo small animal experiments. In addition, new research directions were initiated within the clinic, with the establishment of 87 Th e

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a new cell biology and stem cell laboratory, directed by Dr. Judit Skopal and Dr. Gábor Földes. Research teams include Finnish, Belgian, American and Israeli members, and more and more international relations are being established.

Between 2003 and 2009, the PhD program led by Professor Sándor Juhász-Nagy, and then by Professor Béla Merkely, produced 24 doctoral dissertations, about half of which relied on basic cardiac and circulatory research conducted in the experimental laboratory.

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“It was most ideal to start surgery here” Interview with Professor István Besznyák, tumor surgeon with Széchenyi-award, former director of the lung surgery department You graduated from the Medical University of Budapest in 1956, and chose the field of pathology at the 1st Department of Pathology and Experimental Cancer Research, where you had previously worked as a student. How did you end up at Városmajor, in lung surgery?

My father was a doctor, he directed my path. I wanted to be a surgeon, and he knew very well that pathology and histology provided the best foundation. So I went to the 1st Department of Pathology and Experimental Cancer Research to work with Professor Baló. I completed my specialty board exam there, with distinction, after which Professor Baló called me in and said: “How come you never said you wanted to be a surgeon?”.

My answer was: “I did tell you, professor, only a long time ago.” We parted with good feelings, and continued to stay in touch.

For three years, I served as the professor’s classroom attendant, which included being there at his lectures to hand out dissections to the medical students for observation. Thus, I saw many rare dissections, which most doctors in Hungary did not get to see. We spent many hours at the institution, and wrote several publications. However, after the specialty board exam, an opening became available at the Városmajor Clinic at Professor Kudász, and I decided to leave the Department of Pathology.

Am I right in thinking that back then a doctor worked in a much wider field?

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with several fields, individual professions in themselves. Consequently, I have been able to write over 300 scientific publications.

At the same time, working with patients has always been a priority for me. At Városmajor, I found a friendly atmosphere among colleagues. I did not have a family back then, and spent all my time here. I went on foreign study trips, to the United States, to Boston, to Harvard University for research work for three semesters, to Cambridge for a few weeks, and to Stockholm. Then I used these experiences in my work.

Looking back on your career, you have come a long way from Városmajor, receiving Széchenyi-award in 2002, and the Commander’s Cross in the Order of Merit of the Republic of Hungary in 2011. What did you gain in Városmajor that helped you along?

It was essential to start with pathology, and then get to a place where it was valued.

Professor Kudász also had basic training in pathology. It was also important that in Városmajor, we did not just “cut and sewed”, but looked at everything in a larger perspective, trying to find reasons and correlations. All in all, it was ideal to start surgery here, because one could learn both the basics and the higher level things as well.

Professor Kudász was a real gentleman, careful about appearance as well. He was a good example to the students, they learned to put on a decent robe when visiting the ward, and to be clean and elegant in surgery. I think, I hope I was able to pass some of this on, since seven of my students are in leadership positions either in Hungary or at abroad. Plus I owe my wife to Városmajor, she was the head nurse of the intensive care unit at the clinic, this is where we met, and have been living in undisturbed happiness for decades now.

Your main research field is cancer and anti-tumor drugs, as well as surgical oncology. In your opinion, where is the treatment of cancer heading to, what are the new directions?

The path of the future is discovering the cause of cancer. At the clinic, we treat and push back the symptoms, the patient’s complaints. Maybe in 50-100 years, I wish it was sooner, we’ll get to learn the cause of certain tumors, and be able to extinguish the cause.

It might sound strange from the mouth of a surgeon, but I wish there was no need for operation in treating tumors, because they could be treated by pharmaceutic intervention and prevention.

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“Medicus nihil aliud est quam animi consolatio.”

(A physician is nothing but a consoler of the mind.)

(Petronius 42.)

The pioneer of vascular surgery National Institute of Vascular Surgery (1975–1981) Just like cardiac surgery, vascular surgery can also be traced back to the Second World War and to the new clinic back then, directed by Professor Imre Littmann.

We should note, however, that Dr. János Balassa conducted carotid aneurysm surgery as early as 1851, used narcosis, and was a world-wide pioneer in stopping traumatic aneurysm with the help of electricity. The vesselsowing method developed by Carrel was used by Bakay on humans as early as in 1911. Apart from traumatic cases, elective reconstructional surgery started in 1953, when Soltesz and Littman conducted the first successful artery poplitea closures.

Prof. Dr. Lajos Soltész Professor Imre Littmann wrote the following in pre­ face to a book written by his students: “Every line of this book resembles protective care, anxiety for patients, willingness to help, as well as true profession of faith instilled in the students. All those who learn this, as well as the mere objective facts, will be excellent associates in the responsible work of doctors.” And the two adjuncts, tall and handsome colleagues, Dr. Lajos Soltész and Dr. József Tóth, were good doctors, providing comfort. They shared a changing room, and the youth called them the “two Sams” among themselves. Dr. Lajos Soltész thought of himself as “pater familias”, and tried to be worthy of that title of honor.

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The life of a “pater familias” Lajos Soltész was born in Mezőtelegd, in 1917. He graduated from the Piarist Highschool of Debrecen. His perspective on life and his alliance to principles reflected strict religious training. We have reason to believe that he was not just religious, but a man of faith as well. He became a doctor in 1942, and was summoned to the army. His younger brother was reported missing in the Second World War, he also had four younger halfbrothers.

His first real workplace was in the town of Balassagyarmat, where he learned surgery from the senior doctor, Kenessey, who must have been a good teacher, because the hospital now bears his name. After the war, Professor Petrovszkij was a forerunner in many surgical fields, and he gathered many well known, talented surgeons around him, including Lajos Soltész.

During the so-called cold war period, surgeon training, in preparation for a new war, had a preeminent place in medical policy. Thus, János Sanatorium was turned into a postgraduate surgery training clinic, directed by the young Dr. Imre Littmann. He carried on a progressive, rejuvenating, modern personnel policy. Looking at the names of those who came to the clinic during this period (Robicsek, Ungár, Temesvári, Árvay, Imre Szabó, Tóth, etc.), along with Dr. Lajos Soltész, the professional foundations of a new era begun to be laid down. Dr. Lajos Soltész ascended fast on the professional ladder, he soon became an assistant professor and then a university professor. His main interest was vascular surgery. His candidacy thesis dealt with arteriovenous shunts. He conducted the first proper venous reconstructive surgery (popliteal replacement, 1953), and many other first-time interventions in Hungary. He contributed to Hungarian vascular surgery not only as a surgeon, but as a teacher as well. He organized an angiology section within the Hungarian Surgical Society, and then helped to establish the Hungarian Society of Angiology and Vascular Surgery.

The pioneers of cardiovascular surgery were in essence: –– Professor Imre Littmann, the “root” (in his era, the institutional name of Városmajor was Postgraduate Surgery Training Clinic), –– Professor József Kudász, the “virtuoso” (the institutional name changed to 4th Surgery Clinic), –– Professor Lajos Soltész, the “pater familias” (employed by the National Institute of Vascular Surgery), 94 Th e

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–– Professor Zoltán Szabó, the modern manager, the “organizer” (by this time, the institutional name was Department of Cardiovascular Surgery).

They all made substantial contributions, often compensating in areas where their forerunners left a possible breach.

Dr. Soltész became director of the Városmajor Institution (then 4th Surgery Clinic) in 1975, with the retirement of Professor József Kudász, and changed the name to National Institute of Vascular Surgery. But progress had already started. The clinic’s historical records reflect conscious intercommunication, the pursuit of scientific validity: –– May 17-18, 1971 – Prof. Pakrovszkij, vascular surgeon from Moscow, conducts an aortic bifemoral bypass surgery at our clinic.

–– January 26, 1972. Professor Siska from Prague visits our clinic –– September 19, 1972. World-famous Italian professor (Malan syndrome) holds scientific lectures at our institution.

–– May 10, 1873. Michael DeBakey, the American vascular surgery “pope”, conducts an aortic bifemoral bypass surgery at the Cardiology Institution. Dr. Lajos Soltész assists. The first Hungarian intervention took place in 1967, and lasted for six hours. After the presentation – where everything was done within an hour and a half –, even the youth were able to do Y-passes within two, two and a half hours.

–– December of 1973. Vascular surgeon Professor Heinrich from Rostock holds post-gradual training at our institution.

–– January 31, 1974. New x-ray machine, developmental step in angiology (DSA).

–– June 20, 1974. Professor Petrovszkij (who became Minister of Health in the Soviet Union) visits his former students.

“Vascular surgery epitome” Lajos Soltész, the “vascular pope”, as Dr. Imre Szabó called him in a memoir, furthered the cause of vascular surgery with much organization and assistance, even before becoming director of the department. In honor of his work of making vascular surgery a field of specialty in medicine, he received that certificate “honiros causa”. Serious illness prevented his further participation, and the establishment of a Professional Collegiate of Angiology, as well as the National Institute of Vascular Surgery fell to his successors. In 1980, his book entitled “Vascular surgery epitome”, co-authored with Attila Nemes, was 95 Th e

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published and became a major textbook. Thanks to his talented students (Dr. Sándor Papp, Dr. Imre Szabó, Dr. Csaba Dzsinich, etc.), we were able to do all routine surgical invasions, carried out in the West, at our clinic. He was a great supporter of abroad study trips for the youth.

He went to America and Austria in 1980 still, but was already weak in the flesh. In early 1981, he was diagnosed with malicious tumor. To people chastising him for smoking, he said: “Why, you old man, would you like to live forever?” His decline was rapid.

Those close to him visited his bedside one by one. He said good-bye to all. They loved him, as their successful but meek “pater familias”. The Hungarian Angiology and Vascular Surgery Society awards someone with a Lajos Soltész memorial medal every other year, who then gives a lecture at the Angiology Days.

Recognizing the role of radiology In former times, the radiologist provided background service only. In practice, this meant that if the clinical doctor had a radiology question, he wrote it down, sent the patient with it to a radiology test, the radiologist conducted the test, wrote down the result, and sent it back. In the decision-making process, his was only one of the many opinions, taken into account or disregarded at will. At least this was the general experience.

However, at the National Institute of Vascular Surgery, under the direction of Professor Soltész, cardiac surgeons and vascular surgeons looked to radiologists as partners, with a co-operative approach. The former director, Dr. Gyula Kisvárday, was interested in cardiology as well, and had an overarching hemodynamic approach. His students, Dr. Iván Pénztáros and Dr. Dezső Antal, followed in his footsteps.

The procedure was this: heart catheterization was conducted by Dr. Elemér Czakó, cardiologist, results were written down with Doctor Pénztáros. When the imaging was done, five or six doctors gathered in the dark room to look at images and set up the diagnosis. The radiologist was always part of the team.

Artery or vein tests were first conducted by vascular surgeons, the radiologist was responsible for setting up the machine, providing proper expositions, and arranging the records. Later, when Dr. Czakó came to the institution, he conducted most of the vein tests, but the radiologist continued with the records. They did not have the kind of teams set up with the cardiac surgeons, but the vascular surgeons consulted with the radiologists one on one, so there was a partnership even back then.

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From left to right: Dr. András Gömöry, Professor Petrovszkij, Professor Kudász, Dr. Katalin Szánthó and Professor Soltész

Types of vein tests Dr. Iván Pénztáros and Dr. Dezső Antal did not wish to conduct angiography or heart catheterization, they left it to Dr. Czakó. Dr. Elemér Czakó was a cardiologist, and thus favored cardiac tests, but he also carried out vein tests with exactness. However, he did not have much time for detailed, selective tests. The following kinds were conducted: carotid and artery subclavian, or anonyma test, which was in essence aortic arch angiography.

These tests helped to detect vascular stenosis. Carotid angiography was rarely conducted, due to fear from complications.

The exact condition of the veins was not always possible to detect, because if one carotid fork could be seen, the other was usually hidden, along with the subclavian vein.

When both the abdominal aorta and the lower limbs were ill, lumbar aortography had to be conducted. The procedure was prescribed by Reynaldo dos Santos in the 1930’s, so 97 Th e

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Professor Lajos Soltész (middle) among disciplines

that was not considered modern in the 1970’s. The patient had to be laid on the stomach, with a pillow beneath.

Sterile wash, anesthesia, and a 15 centimeter long needle had to be inserted through the lumbar muscles into the aorta, if possible above the renal artery. Even with anesthesia, patients had a strong repugnance for this procedure.

The 100 ml Uromiro contrast media was inserted and ran through the aortic-iliafemoral section. The patient had to wait with needle in the back, until the image was developed (8-10 minutes). If a mistake blurred the image, the test had to be repeated.

Apart from x-ray images from both sides, sciascopy was also an important diagnostic tool. We had a Siemens-type machine from before the war. The image was projected on a round mirror, small but very good quality. This machine was especially important in cardiac tests, because there was no cardiac ultrasound yet, so finer wall movement deviations, counter-pulsations, auricle depth, valve sclerosis, artificial valve functions, and a lot of other parameters could not be detected in other ways.

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The newest techniques In the fall of 1978, the x-ray department got a new director: Dr. László Szlávy, an expert in angiography, due to study trips to Sweden and to Boston (Harvard University, Professor Abrams). He immediately set out to establish new test techniques. Today, it is natural to have an invasive radiologist conduct super-selective angiography. Back then, selective, multi-directional testing was revolutionary. Images became unambiguous, leading to responsible diagnosis. Expressions, such as “I think”, “I believe” soon disappeared from the radiologist records.

Dr. László Szlávy had marvelous energies, he aimed for the impossible, and proved that it could be done. In 1978, it was not customary to go to conferences held in western countries. When he received an invitation to an IUA conference held in Athens, he encouraged his young doubtful colleague to sign up as well, “we’ll take care of the

Starting the day in the surgery room

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rest” - he said. And so it was. In 1981, the first DSA machine was installed, new not only in Europe but in America as well. When Professor Abrams, visiting at the time, saw the machine in operation, he confessed that the same machine was only in the set up stage at Harvard.

The greatest accomplishment of Professor Szlávy was the establishment of the radiology center in Határőr street with the first CT and MR machines. We stood amused at the things he was able to arrange and achieve. His firmness – you could say, unreserved in a good cause – evoked clashes of interest as well, so there were many who did not like him. He was generally kind to his immediate associates, with a positive attitude, but had reservations towards them as well. For example, he could never forgive Dr. Iván Pénztáros for his unwillingness to conduct angiography. The atmosphere around him was always somewhat heated. He felt it, and tried to compensate by always being gentleman-like, never raising his voice. However, this awkward courtesy was sometimes worse than an explosion.

Some colleagues, for example Dr. Pénztáros, left the clinic, not necessarily because of Professor Szlávy, but the atmosphere was not the same as in old times.

Dr. László Entz had long desired to become a surgeon. Professor Soltész promised to receive him at the vascular surgery department, but his sudden death prevented the fulfillment of this plan. Professor Zoltán Szabó made it up a year later. The young Dr. Kálmány Huttl came to his place from the Radiology Clinic. Dr. Imre Répa also arrived, from the town of Vác, leaving behind internal medicine, coming here to learn invasive radiology.

This was the summit and the closing of the era of invasive radiology, to be replaced with the era of interventional radiology, still in operation today.

Városmajor as a vascular surgery school From Hippocrates until today, treating the injuries of the artery has always been a common pursuit of surgery. In most cases, artery ligation was conducted, during which the surgeons tried to find the right proportion for the limb to survive. The following data will reveal the development of vascular surgery: –– In the Second World War, vascular casualties received treatment within 15,2 hours in average, and the amputation proportion was 40%.

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–– In the Korean war, the waiting period was down to 9.8 hours in average, and the amputation proportion was 25% (reconstruction was already in practice).

–– In Vietnam, artery reconstruction took place within 70 minutes, and the amputation proportion was only 5%.

Table 1: Vascular surgery dates at the Department of Cardiovascular Surgery and its forerunner, the 4th Surgery Clinic. Quality measures.

Surgery type

Date

Poplitea replacement

1953

Abdominal aneurysm resection

1960

Carotid reconstruction

1963

Vein replacement with plastic

1964

Anonym reconstruction

1966

Aortobifemoral bypass

July 1967

Aortorenal bypass

September 1969

Aortomesenteric bypass

September 1969

Aortobifemoral graft replacement

1974

Vena iliaca thrombectomy

1979

Aortobicaroticus bypass

1980

Aortic arch replacement

1986

Eversion carotid endarterectomy

January 1991

EVAR (aortic stent graft implantation)

2003

Table 2: Quantity measures at the clinic Time period

Surgeries conducted

1952-1960

out of 1,684 surgeries, 8 tea

8 bypass

11 thrombectomy

1978-1985

6,307 surgeries – reconstructions only

1992-1999

11,368 surgeries – reconstructions only

2000-2006

15,041 surgeries – reconstructions only

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Table 1 and 2 include a lot of data, but leave out many priorities as well. Initiatives in angiology (disease description, pathology, conservative treatment), led to three vascular surgery schools: –– Soltész-Szabó-Ranki-Molnár-Frank-Loblovits took their first steps in the Városmajor Institution, under the direction of Professor Littmann, and then of Professor Kudász.

–– The team of Dr. Tibor Kiss (Bertalan Márk, József Lelkes, Lajos Kollár, György Wéber) carried out pioneer work in Pécs.

–– Professor Stefanics supported the work of Balázs Gergő Papp in the Clinic of Baross street. It is interesting to note that two of the three “schools” started in places where cardiac surgery was present as well. At the clinic directed by Professor Littmann, Dr. Lajos Soltész was the most outstanding figure of Hungarian vascular surgery.

He organized and directed angiology as well. In 1962, with the help of Dr. Károly Bugár-Mészáros and Dr. László Urai, the Angiology Section was established within the framework of the Hungarian Surgical Society. The society’s chairmen included renown professionals, such as Dr. Károly Bugár-Mészáros, Dr. Lajos Soltész, Dr. László Urai, Dr. Zoltán Szabó, Dr. Csaba Dzsinich, Dr. Attila Nemes, Dr. György Acsady, Dr. Lajos Kollár, Dr. Lajos Mátyás and Dr. István Mogán.

The National Institute of Vascular Surgery and the Professional Collegiate of Angiology was established by Professor Zoltán Szabó, at the initiative of Lajos Soltész. Since 1980, vascular surgery specialty board exams have also been conducted.

In line with international achievements, the first successful interventions were conducted (table 1). Surgical numbers rose as well (table 2). All representatives of Hungarian vascular surgery had ties with the Városmajor school, established by the pioneer professor, Lajos Soltész. Dr. Sándor Papp participated in a short scholarship program in France, and then helped the technical development of vascular surgery with reconstruction efforts.

Following the early death of Lajos Soltész, he became the director of vascular surgery, with the assistance of the cardiac surgery director, Professor Zoltán Szabó. They helped the new generation of vascular surgeons in their advancement: Dr. György Acsady, Dr. Csaba Dzsinich, Dr. Attila Nemes.

Dr. Imre Szabó, the quiet man with excellent hands, who was there at the beginnings, seeing both success and failure, raising generations of new doctors, is still working today.

It’s worth to look at tables 1 and 2 again, and compare Hungarian vascular surgery with 102 Th e

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international results. Balassa came before Eastcott and Matas. Bakay adopted Carell’s vein stitch method right away. Four years after Kunlin’s first arterial bridging, SoltészLittmann conducted a similar surgery. Nine years after Dubos’ successful aneurysm repair, came Soltész’ invasion. Aortic arch replacement had to wait 30 years in Hungary. At the same time, eversion carotid endarterectomy was applied soon after its appearance in the world, and we did not have to wait much for the first stent grafts insertions, either.

In relation to vascular surgery, we can talk about the following time periods: 1950–1960: pioneering, 1960–1970: routine interventions appear, 1970–1980: change in quantity, great series, 1980–1990: countrywide dispersion, acknowledgment of the profession, 1990–2000: new procedures, the unfolding of interventional cardioangiology, unprecedented development.

At the time of Professor Soltész, the Hungarian pioneers of angio-radiology were: Dr. László Szláví, Dr. Imre Répa, Dr. László Horváth, Dr. Kálmán Huttl and many others. Percutaneous transluminal angioplasty (PTA) in vascular surgery, and percutaneous transluminal coronary angioplasty (PTCA) in cardiac surgery, are now acknowledged methods, more and more are conducted with the use of stents.

In 2000, at our clinic, out of 580 coronary operations, 384 were PTCAs, while out of 2969 vein reconstructions, 279 were PTAs. Countrywide, these numbers in 2000 were: out of 12 884 vein reconstructions, 2057 were PTAs, and out of 3728 coronary operations (2,6% mortality rate), 3225 were PTCAs.

“He was the vein pope” The following portrayals illustrate the 1975-1981 period of fast-paced professional development.

Dr. Imre Szabó said the following about Professor Lajos Soltész: “Lajos Soltész replaced Professor Kudász in his chair. Soltész was a friend of mine, we worked together for 28 years, and spent together many evenings, in company with his favorite brandy.

Our friendship had an interesting start. I had a short-story fiction book in my hands, writ103 Th e

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ten by Gyula Krúdy, one of his favorite authors. We became friends, and he invited me to work at his department. Back then we did not have a chance to travel abroad, we learned our profession by putting into practice the things we read about in books and papers. Often we wrote scripts for the first surgeries, complemented with drawings, visually setting up the procedure. As we got more experienced, this became unnecessary. We practiced artificial vein implantation on dogs at the experimental laboratory. He was fanatic about vascular surgery, although his hands were not as artful as that of the technique characterizing Professor Kudász.

He had lasting merits in the establishment of vascular surgery in Hungary. He organized the Hungarian Society of Angiology, which he continued to lead until his death. He fought for the establishment of county vascular surgery centers, and for the possibility of vascular surgery specialty board exams. He accomplished all of this with quiet meekness. People looked up to him. He was the “vein pope”. Everyone loved him.

He was a true gentleman with a good sense of humor and practically no enemies. He could have used a bit more harshness in directing the clinic, but I never knew a better man there.”

His colleagues wrote the following about Dr. Sándor Papp (1923-2006) in a memoir: “He spoke excellent French, and went on a 3-month study trip to Strasbourg in 1967. There, with the help of Professor Kieny, he became familiar with the recent accomplishments of French vascular surgery. He then applied many new surgery techniques at home. In 1969, he conducted the first aortobifemoral bypass surgery, and then the first carotid endarterectomy in Hungary. As vice president of the Department of Cardiovascular Surgery from 1976, as a board member of the professional society, and as a member, then the chairman of the specialty exam’s board, he had an important role in Hungarian vascular surgeon training, as well as in the establishment of high professional standards.

Sándor Papp had excellent surgical skills, and a high level of professional awareness, which enabled him to improvise and came up with amazing solutions, which later became routine procedures.

His professional accomplishments were honored with a Balassa Memorial Lecture by the Hungarian Surgeon’s Society, and a Soltész Memorial Lecture by the Hungarian Society of Angiology and Vascular Surgery. He operated until his 76th year. He did not aim for cheap popularity. He held distance with a sarcastic sense of humor, and only a few could enjoy his sparkling intelligence. In his old age, he became more cheerful. During the last few years, he battled with a serious illness and had many operations.”

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We need a team!

Dr. Imre Szabó and Dr. Sándor Papp were outstanding characters in the establishment of Hungarian vascular surgery. But surgery is teamwork. Below we list colleagues from this era, hoping not to leave out anyone: Dr. Csaba Dzsinich – now a professor –, an excellent colleague with artful handwork.

Dr József Frank, who then retired as the department’s director. He was a party leader as well, but a benign, helpful leader.

Dr. Eszter Turbók operated as well, but became well known as a vascular surgery anesthesiologist.

Dr. Ádám Balogh – now professor emeritus – who later built on vascular surgery experience he gained here, just as Dr. Miklós Sebestény.

Dr. István Mogán – as department director – who went to a large vascular surgery department in the capital.

Women operated as well, with inherent accuracy so uniquely theirs: Dr. Zsuzsanna Járányi, Dr. Ágnes Laczkó, Dr. Anna Mezővári.

The adjunct, Dr. Gábor Bíró, now has a developing career.

Dr. László Entz started as a radiologist, he is now director of the Vascular Surgery Department. In the eyes of many, he is the “pater familias” style colleague, just as Soltész once was.

For a short period, Dr. László Ranki worked at our clinic as well, an accomplished vascular surgeon.

Dr. Zoltán Szabolcs, cardiac surgeon, started his career at the vascular surgery department of our clinic.

Dr. György Acsady, former clinical director, was invited to our clinic by Professor Soltész.

This is teamwork. Many assisted and took part in vascular surgery. Under the directorship of Soltész, Dr. Attila Nemes also worked here for an extended period.

The clinic was the center of postgraduate vascular surgery training, and from 1980, also the center of specialty board exams. All county vascular surgery departments have a colleague who once attended postgraduate vascular surgery training here.

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Structural changes within the clinic With Professor Soltész appointed to directorship, the clinic’s whole structure and doctoral staff changed, not only it’s name. The cardiothoracic surgery department was discontinued at the National Institute of Vascular Surgery. Dr. István Besznyák went to lead the surgery department of the Countrywide Institution of Oncology, taking Dr. Ádám Balogh (who later became director of the surgery clinic in the city of Szeged), Dr. Zoltán Sulyok, Dr. László Tóth and Dr. Miklós Sebestény with him. Two programs continued: vascular surgery and cardiac surgery.

Suspicions arose that cardiac surgery would be discontinued as well, so Dr. Zoltán Szabó, head of the work group, looked for a solution. He started negotiations with Dr. Attila Naszlády, director of the department of cardiology at Korányi Sanatorium, who was happy to hear from him. The idea was to move cardiac surgery to the former place of urology at the Cardiothoracic Surgery Department of Korányi. They’d “only” need to install two surgery rooms, but the department was located on the top floor of the Sanatorium, and heart patients would have found it hard to go up there.

Cardiac surgery: passing the magic hundred Professor Soltész heard of these plans on an abroad trip, and upon returning home, he immediately sat down with Dr. Zoltán Szabó, assuring him that the institution needed cardiac surgery, the department was to continue without disturbance. Under these circumstances, it was possible to pass the magic hundred number in surgery, there were 101 interventions in 1974. In 1980, there were 230, and in 1981, there were 253.

This growth had multiple reasons. Close professional ties were established with several cardiology centers, the Bajcsy and János hospitals. The number of children coming for surgery with congenital heart defects rose as well, because back then Dr. Elek Bodor was the only one conducting catheter-based artery tests with Seldinger technique. In consequence, Dr. János Kamarás sent all children with congenital artery vitium to the institution, and the surgery repertoire included rare cases, such as supravalvular aortic stenosis as well. Dr. Ferenc Rényi-Vámos reported on 12 such children’s surgeries in Rio de Janeiro, at the Cardiovascular World Conference of 1983.

Growth in numbers also had to do with faster surgeries, less surgery time.

The extra-corporal surgery program changed as well, half of the interventions were 106 Th e

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done with artificial cardiac valve. Most of these were Starr-Edwards silastic ball valves, as the newer, disc-shaped (Cross-Jones) valves often resulted in malfunction within a year or two.

Successful xenograft implants Scientific papers published several articles about the excellent hemodynamic qualities of xenografts preserved in glutaraldehyde. In the second half of the 1970’s, two kinds: Carpentier-Edwards and Hancock valves became available. Xenograft implantation in Városmajor started in 1976. The first results were so promising, that there were 121 implantations within three years. Dr. Zoltán Szabó reported on these results at a bioprothesis symposium, held in Munich, in March of 1979. During this year, 95% of implanted valves were xenografts. 1978 was the year when a patient survived a triple valve implantation.

The good results were also due to the fact that cardiac surgeons started to apply cold cardioplegia for heart muscle protection. First they used the original, prescribed solution, then they changed it a bit, because Dr. Endre Moravcsik found out in experiential clinical research that the solution’s pH value changed in storage, it became more acid.

They restored the solution’s chemical reaction and elevated its osmotic pressure, making surgical results even better – perioperative mortality rate dropped well below 10%.

The start of coronary operations Even in the early 1970’s, several international publications dealt with coronary surgery.

In the middle of that decade, doctors at our institution were ready to start with such interventions, but there was no infrastructure to it. Coronarography was started by Dr. László Szlávy at the Radiology Clinic, patients were sent to him by ambulance, he did the tests, and sent them back. This method did not work well, because there were many side effects. At the advice of Dr. Zoltán Szabó, Professor Soltész asked Dr. Szlávy to come to the clinic. Dr. Elemér Czakó soon learned the testing method from him, so the two of them were now able to do coronarographies.

Initially, the question arose whether coronary bypass belonged to the field of vascular or to the field of cardiac surgery. Professor Soltész visited the pathology institution with 107 Th e

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a cardiac surgery team, and they did some cadaver bypass. This convinced the director that coronary operations belong to the competence of cardiac surgeons. It took a while to establish a unified nomenclature as well.

The first bypass operations consisted of bridging. The first double saphenous bypass took place at the end of 1976 only. By the end of the decade, the team got to the point of undertaking multiple bypass. By 1986, more than half of the interventions were coronary operations.

Cardiac surgery as an independent discipline Scientific work was very active in this era as well. Professor Ferenc Solti, the cardiologist, had several publications on arrhythmia and pacemaker-treatment in western scientific papers. Other members of the team also had papers in the press both at home and abroad. In 1981, Bodor defended his candidacy dissertation, and later Renyi did the same.

Colleagues of the institution gave three presentations at the pacemaker world congress in Montreal, in 1979. In addition, the work of the institution was presented regularly at the cardiology congresses held in Balatonfüred.

In 1979, the ministry acknowledged cardiac surgery as an independent discipline.

Dr. Zoltán Szabó, Dr. Elek Bodor, and a year later, Dr. Ferenc Rényi-Vámos received a “honoris causa” cardiac surgeon title.

At the clinic in Munich, Professor Zoltán Szabó went to a Christmas party. At home, he organized a similar event for his colleagues to acknowledge their work that year. In 1976, this party was held at the library, for the staff of the Cardiac Surgery Department.

It turned out so well that there was a great demand for it next year. From 1979, the party was held at a place of amusement and music. As we will see in the next chapter, this Christmas party became an event involving the whole clinic, when Professor Soltész passed away and Dr. Zoltán Szabó became director.

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“Lajos Soltész taught me as his own son” Interview with Professor Péter Gloviczki, who started his career in Városmajor, and now serves as chairman of the American Society of Vascular Surgeons

As you said, people often introduce you by saying: this is Péter Gloviczki, who is a great loss to the art of magic, but a great gain to surgery. Looking at your career, you could be a professional magician as well. When did the lot fall to the field of medicine?

I come from a family of physicians, my father was an internal doctor and a neurologist, practicing in the town of Nyíregyháza, where I was born. Then we moved to the capital, to the Pest side, where he worked as a local doctor. He is my greatest example to this day, the pattern he set determined the kind of doctor I wanted to become. I decided very early that I would choose his profession. When I was six years old, and people asked me what I wanted to become, my answer was: a surgeon. Why? My father had a surgeon friend in Nyíregyháza, and upon seeing him, I decided that this is what I wanted to do.

At the same time, your interest in the art of magic at the age of 10 also had to do with a colleague of your father.

That’s right. I learned the first tricks from a colleague of my father, Sándor Takács, who was a member of the Society of Hungarian Amateur Magicians. That’s where I started the art of magic as well, and at the age of 14, I won a category 1st place of a talent show.

This opened up many opportunities for me, I traveled a lot, learned various languages, and met a lot of people. In 1973, I won a silver medal at the World Championship of Magic in Paris, and in 1975, I got an offer from the Olympia in Paris to work as a 109 Th e

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magician there. At that point, I had to decide for good. But as I said, I always wanted to be a surgeon.

In an earlier interview, you said you still owed much to the talent show. I heard that it had something to do with getting a job at Városmajor, too, right?

After graduating from the high-school in Pannonhalma, I went to the Semmelweis Medical University, where I got my diploma with a golden ring level, meaning that from 1st grade in elementary school to graduating from the university, I always had straight As in my school reports. So I felt I had a good chance of getting accepted at wherever I wanted to go. First I did not know which field I should choose within surgery, then I saw an advertisement for a vascular surgeon position in Városmajor. I went to see Professor Lajos Soltész, then director of the Vascular Surgery Department, who knew my father, but it was József Kudász, the director, who had to be persuaded to accept me. First he did not want to see me, but I waited at his office for two hours, and then he came out.

He said he did not want someone fresh from the university. Experience in pathology was mandatory. I said: “Here is a letter of recommendation from Professor Harry Jellinek, I worked at his pathology as a student for three years.” He said: “Good, but you have to speak languages too.”

“I went to university competitions in six languages” – I replied. At this point, the secretary of Professor Kudász, Márta Juhász came in, heard some of our conversation, and asked: “Are you the little magician?” Professor Kudász looked at me, and said: “You know what, Gloviczki, I will recommend you.”

What did the years you spent in Városmajor mean to you? To be a Soltész-student?

Lajos Soltész raised me as his own son. He was the first to call my attention to the fact that vascular disease includes not only problems of the arteries, but of veins and lymphatic vessels as well. Vascular surgery has to take care of varicose, leg ulcer, lymph-edema and vascular malformations too. At the clinic, I met several giants of vascular surgery in the early 1970’s. One of them was the Italian Professor Malan, pioneer of vain malformation research. Another was the Austrian Robert May, and we heard first-hand experiences from the disease we now call May-Thurner syndrome. In 1975, Lajos Soltész got me a year’s scholarship in Paris, that’s where I started to learn about lymphatic microsurgery, and wrote a dissertation on lymphovenous anastomoses. Upon returning home, I first took a specialty board exam in general surgery, and then one in vascular surgery – with the first class to do so.

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After returning from Paris, how did you decide to go abroad again, this time for a longer period? And first of all, how did you make it to the citadel of medicine: Mayo Clinic?

After my studies in Paris, I presented the experimental work I conducted there at several universities. At such an event, I met Alexander Schirger, angiologist, who worked at Mayo Clinic. His father was Hungarian, from Kosice. With his assistance, I won a scholarship for Eastern European doctors. I left in the year of Professor Soltész’s death, whom I considered my second father. I did not come with the aim of staying here, but when time was up, I contrasted my possibilities here and those in Hungary, and the decision was clear. The loss I felt at the death of Professor Soltész also influenced my decision. In 1982, I stayed here for good. At the same time, I continued to keep in touch with Hungary, professionally as well. Several Hungarian colleagues came to visit, and I am an honorary member of several Hungarian societies in the profession.

What did you have to do to earn distinctions at such an excellent place as Mayo Clinic? Did you have to prove yourself more, having arrived from Hungary, from Eastern Europe?

I was attracted here by the endless professional possibilities and professional freedom I experienced. I felt at home right away. I came here 30 years ago as a first generation Hungarian, I directed the Vascular Surgery Department of Mayo Clinic for 10 years, and I am now chairman of the American Society of Vascular Surgeons, which is the number one vascular surgeon society not only in America, but in the world too. I have everything a good surgeon can attain. What did it take?

It took a lot: hard work, professional devotion, and – as I now look back – huge selfconfidence, after all. Back then, I did not call this self-confidence, but it was a feeling that there wasn’t anything out there that I couldn’t do. Of course, you had to have a balanced character, I always knew when it was time to prove myself, and when it was time to stay in the background. Talent, craft, and good luck are also needed in this profession.

You mentioned craft – at this point, vascular surgery and the art of magic surely relate to one another.

Both the magician and the surgeon has to have crafty hands, that’s true. But I stack with the art of magic also because our profession is so demanding that I have to do something that’s different from operations. I do magic tricks to this day at medical conferences, and 111 Th e

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the patients too know this side of me, not just the colleagues. At our clinic, all doctors have a so-called door card, with a symbol that characterize them, instead of their names.

These cards are on patient room doors at the clinic, so the doctors know during the visit where their patients are. On my card, there is a Hungarian flag, a magic cylinder, and a surgeon’s hand with a dissector, which looks like a wand. Thus, people know everything about me, that I’m Hungarian, I’m a magician and a surgeon.

As chairman of the American Society of Vascular Surgeons, what do you see, how does the future of vascular surgery look like?

Splendid! Vascular surgery has come a long way, especially endovascular surgery with minimal invasive interventions. Now we do not cut an abdominal aneurysm, but operate with intravenous catheterization or stents. This is just one example, we can pretty much do all endovascular interventions intravenously.

Could the prevention and treatment of atherosclerosis develop to the point of making invasive interventions unnecessary?

We are learning a lot with the expansion of genetic knowledge. Today, you can pretty much tell who will have what kinds of illnesses, and there are all kinds of new drugs to influence the development of certain genetic disorders. But since atherosclerosis is definitely a dietetic malady, it could only be solved if mankind could live without fat, cholesterol, meat and cigarettes. If that would happen, we could live a lot longer.

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“Vivere illis non sibi” Living for others, not for ourselves (János Balassa 1814-1868)

From motorized surgery to heart transplantation Department of Cardiovascular Surgery (1981–1992) Prof. Dr. Zoltán Szabó was born in the town of Pécs, on October 23rd, 1929. He went to a Jesuit high-school, and was admitted to the Medical University of Pécs. He became a doctor in 1954, and worked at the 2nd Surgery Clinic of Pécs, directed by Professor Kudász. When the professor was transferred to Budapest, he received associate professorship at the 4th Surgery Clinic (Városmajor), in 1957. The same year, he passed the specialty board exam in general surgery.

He worked in the field of cardiac surgery since 1955.

In 1967, he implanted a self-constructed pacemaker. He wrote his candidacy dissertation on pacemaker therapy. He became a docent in 1975, and a university professor in 1978. He was dean of the Medical Faculty of Semmelweis University between 1979-1985, and then served as general vice president for three years.

In December of 1981, he was appointed president of the Department of Cardiovascular Surgery and the National Institute of Vascular Surgery, as well as president of the Professional Collegiate of Angiology. He gained a chair in the Cardiac- and Vascular Surgery Specialty Exam Board of the Institute of Postgraduate Medical Training. In 1992, he 115 Th e

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conducted the first heart transplantation in Hungary. He has 156 publications, wrote and edited three books, and co-authored five. He received Ferenc Adorján, János Balassa, György Gábor, Ignác Semmelweis and Imre Zardai memorial medals. He was awarded the Commander’s Cross in the Order of Merit of the Republic of Hungary with a star, and a Batthyany-Strattmann prize.

He received a Szechenyi-award in 1997. He retired on July 1st, 1992, and became director of Biotronic Hungaria Ltd., where he worked until January 1st, 2004. He is emeritus professor of Semmelweis University since 1995.

With the sudden and early death of Professor Lajos Soltész, Professor Zoltán Szabó became director, and was so successful that the two decades between 1981-1992 are now looked upon as the golden age of the clinic. Dr. Zoltán Szabó, who witnessed the birth and development of a new discipline, cardiac surgery, had all the virtues one needed to become a worthy successor of Professors Littmann, Kudász and Soltész. He respected and loved his profession, honored the patients, and saw the importance of friendly relationships and a familiar atmosphere with colleagues.

Inasmuch as Dr. Imre Littmann was the “root”, establishing vascular and cardiac surgery in Városmajor, Dr. József Kudász was the one who brought the surgeon’s virtuoso, and Dr. Lajos Soltész created a widely respected atmosphere at Városmajor, then Dr. Zoltán Szabó brought management skills and abilities. He knew where he came from and where he was going. He had a clear vision, and knew the strategies and tactics that got him there.

The Városmajor Clinic became a modern and effective cardiovascular center under the leadership of Professor Zoltán Szabó. In an interview, he stated his credo: “When I became director in 1981, my colleagues looked at the new Countrywide Cardiology Institution, and compared it with our old clinic with envy. In wanting to inspire them, I compared Városmajor to a country tavern with no chandeliers but old lanterns, and excellent food. But that food, that menu was so good that it could be envied by many fine, expensive hotel restaurants.”

Superlative clinic construction Professionally, this era is characterized by dynamic aspirations to bring the clinic closer to European standards both in numbers and in quality. When Zoltán Szabó became managing professor of Városmajor, the clinic had two vascular surgery rooms, one cardiac 116 Th e

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surgery room, an outdated angiography laboratory and a tolerably equipped laboratory. In 1992, when Dr. Zoltán Szabó turned the clinic over to Dr. Attila Nemes, the clinic no longer resembled the clinic from the decade before. It was a most modern, well equipped institution with four vascular surgery rooms, two cardiac surgery rooms and one pacemaker surgery room. Apart from modern hemodynamic and angiography testing rooms, there were CT and ultrasound laboratories. An intensive care cardiac surgery unit with 11 beds, and vascular surgery unit with 9 beds was built. A new, more spacious and better equipped laboratory served the clinic, and a new lecture room became available for university training.

Professor Zoltán Szabó understood that the professional goals he had could not be attained within the narrow institutional boundaries and possibilities of the time. The Városmajor Clinic had been rearranged architecturally about every 30 years: it was built in 1912, rebuilt in 1952 to become a Postgraduate Surgery Training Clinic, and received a new surgery block, intensive care units, diagnosis and training rooms, doctor’s offices

The renovated building of the clinic in 1991

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and nurse changing room sin 1986-87. It is not an overstatement to call Dr. Zoltán Szabó a clinic builder, as well as a manager.

When the new surgery block was completed with 6+1 surgery rooms, the National Institute of Vascular Surgery – now called Central Radiology Diagnosis – received a separate building, where the first Hungarian CT and MR machines were installed. The new surgery block made it possible for us to raise the number of coronary operations, and PCI interventions were started at the new hemodynamics laboratory. Since stents were not yet available, one surgery room was always available during coronary expansion, and if there were any side effects, the patient was transported right away, connected to a heart engine, and we conducted a coronary bypass surgery.

The work of construction and renovation took about a year and a half, but the work of healing did not stop. We operated in former patient rooms that were turned into temporary surgery rooms, corridors were cut in half for construction, and morning conferences were held in the canteen.

Apart from Dr. Zoltán Szabó, Dr. Elek Bodor and Dr. Ferenc Rényi-Vámos supervised the work of construction. From time to time, they arranged for all the staff to see

The new pride of “Városmajor”: the surgery block

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László Medve, minister of health-care gives a talk at the opening ceremony of the new surgery block and the Central Radiology on Határőr street in 1986, at the new lecture hall of the clinic. Professor Zoltán Szabó and members of the administration in the background

the new surgery block being built, and made it possible for all to make comments. As a result, we all felt at home in the rebuilt clinic, and the patients were comfortable as well.

The advent of the computer A modern institution, offering cardiovascular surgery services, can not exist without an effective data management system. At the initiative of Dr. Ferenc Rényi-Vámos, Dr. Katalin Naray, a clinical computer engineer, along with Dr. László Entz vascular surgeon and Dr. Zoltán Szabolcs cardiac surgeon, traveled to Graz in 1988 to study a hospital’s information system. This field was rather underdeveloped not only at Városmajor, but in other Hungarian hospitals as well.

At the end of 1988, typewriters were omitted in surgery recording, and all important patient information was entered into computers in the admission office.

The expanding Naray-made computer program had several query functions. We could find out the number of surgeries and hospitalization days, the age and location of patients, 119 Th e

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the number of acute, urgent and elective interventions, the work of individual surgeons, and the scheduling of surgeries. Now, in 2012, we have a MEDSOL information system installed for billions of Forints, and yet can not access information we had available with that “homemade” system 24 years ago.

Cardiac surgery in acceleration Hand in hand with construction work, professional development in surgery work was also spectacular. In 1981, there were only 253 open heart surgeries, conducted in the only cardiac surgery room of the clinic, while in 1992, 649 cardiac surgery interventions took place in the two cardiac surgery rooms of the new block. This acceleration required new colleagues to join the cardiac surgery team. The team led by Professor Szabó had six members in 1981 (Dr. Elek Bodor, Dr. Ferenc Rényi-Vámos, Dr. Endre Moravcsik, Dr. Tibor Gyöngy and Dr. Lajos Papp), but after 1984, Dr. Zoltán Szabolcs, Dr. Tivadar Huttl, Dr. Ferenc Horkay, Dr. Nasri Alotti, Dr. András Kollár, and then Dr. Endre

Professor Zoltán Szabó and his team in the new surgery room

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­ ovács joined. At the heart catheterization laboratory, the team of Dr. Elemér Czakó and K Dr. László Szlávy was joined by Dr. László Szatmáry, and then – after Elemér Czakó moved to Germany in 1984 – by Dr. Tibor Vécsey.

As the number of cardiac surgeries grew, more anesthesiologists were needed as well.

Dr. Imre Kalmár was the “good old man”, and soon over half a dozen new colleagues furthered his work: Dr. Ida Matkó, Dr. Márta Olajos, Dr. Mária Windisch, Dr. Erzsébet Maklári, Dr. Gabriella Nagy, Dr. Katalin Széphelyi, Dr. Ágnes Petrohai, Dr. Ildikó Gálfy, and Dr. György Nyikos, who expressed their reverence by calling him “Father”.

During this decade, longer post-gradual training sessions became available abroad: Dr. Lajos Papp went to Boston, Dr. Zoltán Szabó, Dr. András Kollár and Dr. Ferenc Horkay went to Leeds, Dr. István Mogán went to Belgium, Dr. László Entz went to Nurnberg, and Dr. Csaba Dzsinich went to Rochester for a year and a half. These study trips helped the faculty with new perspectives, and prepared them to reach their professional goals.

In 1981, we conducted 253 operations in our only surgery room. By 1992, we were conducting 324 operations in each of the two new surgery rooms. Apart from the numbers, we have other things to be proud of during the 1981-1992 time period.

Several surgery types were first conducted in Városmajor among the Hungarian cardiac surgery centers. Due to close collaboration between the vascular and the cardiac surgery programs, Városmajor was the center of aortic dissection treatment by surgery during this decade, patients were transported here from all parts of the country. The older ones still remember the interdisciplinary councils that followed DSA monitoring.

Everyone with reliable opinions and experiences was there: Dr. Zoltán Szabó, Dr. László Szlávy, Dr. Elek Bodor, Dr. Imre Répa, Dr. Csaba Dzsinich, Dr. Ferenc Rényi-Vámos, Dr. Kálmán Huttl, Dr. Tibor Gyöngy, Dr. István Mogán, Dr. Lajos Papp. And behind them, on their side, squeezed in the younger ones – Doctors Zoltán Szabolcs, László Entz, Ferenc Horkay, Tivadar Huttl and others – to determine the exact place of vein wall damage and discuss important details. Rodin could have formed a sculpture of “the thinking doctors” upon seeing our group. No one would have missed these exciting and instructive occasions. These years were fantastic times in Városmajor.

The boundaries of cardiovascular surgery We mentioned the close cooperation and symbiosis of cardiac surgery and vascular surgery in Városmajor. The clinic’s cardiac surgeons were somewhat vascular surgeons as well.

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Apart from handling vascular catastrophes, colleagues at the cardiac surgery department were the first in the country to conduct total aortic replacement (Dr. Tibor Gyöngy, 1986) and total aortic root reconstruction, according to Bentall (Dr. Ferenc Rényi-Vámos, 1987). A great number of other operations, treating descending aneurysms of the aorta, were conducted, which operations belonged to the competence of cardiac surgeons at the time.

The old surgery records reveal that the cardiac surgeon Elek Bodor conducted a successful ruptured abdominal aneurysm surgery. Vascular and cardiac surgery cooperation reached another summit in 1988, when Dr. Zoltán Szabolcs and Dr. István Mogán conducted the first simultaneous carotid artery operation, of which 300 were conducted during the ensuing decades here in Városmajor.

Cardiac valve variants Between 1976 and 1991, 1017 biological and 1876 mechanical artificial valves were implanted at the clinic. Different kinds of pork valve stabilized in glutaraldehyde, sewed on a flexible frame, came into use in 1976. By 1980, 91% of valves used in valve replacement were biological. In 1982, the experiences of the previous five years were proudly reported in medical papers. However, 7-8 years after the implantation, dysfunctions arose due to scleroses and rupture. From the middle of the 1980’s to 1991, 166 patients came for xenograft replacement. The second surgery was not as wearisome for the patients, and not as hard to carry out as we formerly thought, but still, biograft implantations went way down in number by the end of the Szabó-era (diagram 1).

At the time, valve implantations occurred every day. In the early 1980’s, they were more common than coronary bypass. The usual scene we still have a mental picture of, is this: Professor Szabó operates, with adjunct Bodor as first assistant, associate professor Horkay as second assistant, Imre Kalmár as anesthesiologist, Katalin Széphelyi backing him up; Zsuzsa Triffa as nurse, Anna Antal as operating room assistant, and uncle Ferenc Weckermann at the good old PEMCO engine, directing the perfusion. Tissue-sparing preparation, careful but speedy stitches, Bretschneider solution and ice protecting the heart muscles, elaborated workmanship in replacing the deformed valve with the new one, a sigh of relief that nothing broke away. Deaeration and reperfusion. The professor leaves for the smoking room, coffee is brought in for him. He has his own chair, makes a few calls, he is at ease in talking to other colleagues. In the surgery room, the “closing 122 Th e

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ceremony” proceeds, as Dr. Ferenc Rényi-Vámos called it. There is no pressure in the air now, old hospital anecdotes are told, the women receive compliments.

In Hungary, the first coronary bypass was conducted in 1972 (Dr. Endre Bodnár, in Szabolcs street), Mechanical 18 29 119 126 160 183 186 225 217 264 327 245 but there were barely any Biological 178 151 96 78 72 54 24 14 16 18 35 44 196 182 215 204 232 237 209 239 233 282 362 289 coronary operations con- Total ducted in Városmajor, even Diagram 1: Biological and mechanical artificial valve implantations between 1981-1992 (Zoltán Szabolcs, cardiac surgery report, 1992.) in 1981 (diagram 2). After 1983, coronary interventions (CABG, coronary artery bypass grafting) increased every year. In 1987, the number of coronary operations surpassed the number of valve operations. By the end of this era, this ratio was almost two to one.

Everyone had a mask. Great commotion. Blood, bandaged nurses, rushing. Then we pointed out the prime minister to the hunky guard, and everyone calmed down. Except for the prime minister, because he was still facing the operation.

Christmas party, with a unique atmosphere The familiar atmosphere at the clinic became easy to discern at the Christmas party held each December, a few days before Christmas. As the number of colleagues grew at the clinic, we rented larger and larger restaurants to accommodate the event. At the beginning, we went to Csarnok Restaurant at Pipa street, then a few times to the Museum Cafeteria, several times to Sophia Restaurant, and then for a decade to Hotel Flamenco on the lakeside.

The Christmas parties had strict choreography. Men were dressed in elegant suites, women in festive costumes, with a scent of perfume. Champagne and cocktails at arrival, and the company was usually seated by departments. Everyone was invited, so we 123 Th e

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had up to 110-150 participants. Appetizer, soup, and Professor Szabó addressed us. He summarized the accomplishments of the past year, and expressed his thankfulness for everyone’s dedicated work. Then he asked us to pull together to reach next year’s goals, and wished us merry Christmas and a happy new year. Then, just like at home, we mingled with champagne in hand to greet one another and convey good wishes. After dinner, we danced until dawn, and relieved all the pressure of the fall and winter months.

Once we were asked by the porter: “Who are you? Where do you work to have so much love towards one another? We host several events, but such an atmosphere, such heartfelt joy you can only see at friendly gatherings.” Back then, there was more stability, the majority of colleagues worked together for years, so we knew each other well, and this contributed to a familiar atmosphere.

There was one especially memorable Christmas party, that of 1989. We were at Sophia Restaurant, only a few days after the revolution broke out in Romania. The people of Hungary were shocked by the events in Romania, especially in Transylvania. Some had high hopes. When everyone arrived at the restaurant, we turned off the lights, lit candles, and bowed our heads in silence for a minute to express our sympathy and support of what happened in Transylvania. Choked sobbing broke the silence here and there, we were a large family of 120-140 solemn people.

The fulfillment of the “cardiac surgery dream” With construction work, staff enlargement, a steady raise in key numbers (surgeries, side effect ratio, mortality, length of hospitalization), and an atmosphere envied by the whole country – in spite of the unfavorable economic environment –, the clinic was getting ready for the crowning event of this era: the first Hungarian heart transplantation.

The first successful heart transplantation of the world was conducted on December 3rd, 1967, in Cape Town, South Africa. Following this event, the large cardiac surgery centers of the world started their own transplantation programs with great enthusiasm.

The “Kudász-Clinic” in Városmajor was not an exception, either, but the political regime of the time did not endorse this idea. 25 years later, however, Professor Zoltán Szabó, a Kudász-student, had a chance to make this cardiac surgery dream come true. On January 3rd, 1992, he conducted a successful heart transplantation at the Department of Cardiovascular Surgery in Városmajor, the first in Hungary. The patient was Sándor 124 Th e

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Schwartz, a 29 year old male, and the operation was the crowning event of long and careful preparation. At the same time, it opened up the possibility to establish a countrywide heart transplantation program.

Preparations began five years earlier, Professor Szabó and his colleagues were preparing for and anticipating the operation as early as 1987. By the time the clinic’s reconstruction was finished in 1991, they had the whole transplantation script ready, and the leading surgeons, as well as the anesthesiologists had been on study trips abroad in transplantation centers. The transplantation team conducted several “training operations” in the pathology room of another university department, getting familiar with each step in the process.

Hardships also came. We were sad to loose an excellent colleague and cardiac surgeon, as well as a dear friend, associate Professor Ferenc Rényi-Vámos, The first Hungarian heart transplantation who suddenly became ill in 1989, and on January 3rd, 1992. soon passed away at the age of 48. The preparation team lost other members as well, when the cardiac surgeon Dr. Lajos Papp was appointed director of the Department of Cardiovascular Surgery at the Institute of Postgraduate Medical Training, taking two surgeons, Dr. Nasri Alotti and Dr. András Kollár, as well as an anesthesiologist, Dr. Gabriella Nagy, with him.

The transplantation team, however, remained resolute. They received permission, and enjoyed the university’s support. Now they only had to choose, check and prepare the right recipient and wait for a suitable donor organ. On January 3rd, 1992, everything came together for a successful operation. The aim was to make heart transplantation a routine surgery in Hungary as well.

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This became reality, since as of September 2012, during the last two decades, 210 transplantations were conducted in our clinic alone. This number is close to what we see at other European transplantation centers. Our clinic also promoted the start of a successful child heart transplantation program at the Countrywide Cardiology Institution in 2007.

The field of interventions and the pacemaker program The appearance of minimally invasive, catheter-based cardiovascular techniques was an important feature in the 1981-92 period. At Városmajor, it was Dr. László Szlávy, Dr. László Szatmáry and Dr. Tibor Vécsey who introduced PTA and PTCA. Introduction of the latter during the late 80’s did not go smooth. While it had several advantages (shorter hospital stay, less medicament, speedy recovery, etc.), there were numerous side effects at the beginning, and the surgery room had to be in a standby mode during the procedure.

Interventional cardiologists faced no less opposition than the surgeons, but Professor

Sándor Schwartz with a “new heart”, a few days after the operation

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Zoltán Szabó wholeheartedly supported their ambitions and saw their potential. However, the start was full of hardships, and the 1990 report, written by Dr. László Szatmáry, was based on a hundred PTCA results only. Today, a large-scale catheterization laboratory, such as the one we have in Városmajor, processes (now with stents) one hundred blocked arteries in a week. But back in 1992, there were only 32 PTCA interventions for 1 million Hungarian citizens, while this number was 790 in Belgium.

Dr. László Szatmáry was in no doubt a Hungarian pioneer of interventional cardiology. After his postgraduate training year in Toulouse, he became even more enthusiastic about widening the scope of PTCA possibilities. He faced several conflicts, which were burdensome to his mind, and he ended up taking his own life.

While talking about the era distinguished by the name of Zoltán Szabó, we should also make note of the actual clinical status of pacemaker therapy. In the 1980’s, the number one basis of pacemaker therapy was the Cardiology Institution, and Városmajor was number two. Here, the first PM implantation was conducted in 1963. In 1967, Dr. Zoltán Szabó constructed a pacemaker with the help of engineer Bocskay, which was successfully implanted in a 72 year old patient in 1968. The device had to be replaced in 18 months.

The clinic’s “electrophysiological laboratory” in person was Professor Ferenc Solti, who outlined the PM-treatment’s indications. During the three decades between 1963-1992, 6992 new PM implantations took place in Városmajor. It was always Professor Solti who stated the surgery indication, and the implantation was carried out by cardiac surgeons.

Each surgeon had his own pacemaker day, when he conducted up to 4 or 6 pacemaker implantations. Between 1989 and 1991, 90% of PM system implantations were conducted in an outpatient system. Both the technical and the surgical side effect rate were rather low, 2-3% and 3-4%. For young surgeons, pacemaker implantation was one of their first independent surgical procedures. Most devices were one chamber VVI machines (Biotronic, Vitatron, Siemens, Refi card-TUR or Medtronic). The first rate responsive devices appeared in 1989-90 only, and the first double-lead pacemaker was implanted in 1990 at the clinic.

The 1980’s had the role of a “bridge” in the pacemaker program at Városmajor. All research, scientific and innovative electrophysiology work carried out in the 1960-70’s prepared the way for the clinic to become a pacemaker therapy center. In the 1980’s, the clinic provided a reliable laboratory, working with low side effect ratios.

Again, it is important to note the vision Professor Zoltán Szabó had when he singled out a senior medical student, Béla Merkely, who had just returned from a study trip to 127 Th e

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Heidelberg. After graduation, he was invited to the clinic, and soon went back to Heidelberg with a scholarship to learn the newest trends of pacemaker therapy. Upon returning home, he proceeded to turn Városmajor into the number one center of electrophysiology and pacemaker therapy in Hungary.

“Watch the fire and the flood” The decade marked by the name of Professor Zoltán Szabó was one of the most exciting periods of the Városmajor Clinic. In the midst of political, social and financial changes and hardships, the clinic continued to function as a family. In this decade, the staff of Városmajor, led by Professor Zoltán Szabó, had outstanding accomplishments. The clinic was rebuilt. The number of operations doubled, then tripled. New information system was put into place. The heart transplantation program was successfully launched. The technical and human base of cardiovascular interventions was established, the number of specialists grew, long-term postgraduate training programs were arranged abroad, and an

Directorship fell into good hands: Professor Zoltán Szabó and his successor in white, Professor Attila Nemes

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intense research program started. Due to effective coronary protection, the mortality rate of open heart surgeries became better (1990:7,7%; 1992:3,5%). With a successful heart transplantation in 1992, the clinic reached the summit. Everyone was surprised when Professor Szabó suddenly announced his intent to retire. As he said, one had to stop on the top, and he did retire in July of 1992, but never quit his active concern for cardiac surgery. At the farewell dinner in his honor, Professor Zoltán Szabó asked the doctoral staff and Professor Attila Nemes, his successor, to keep up the work, and “watch the fire and the flood”. The creation, the myth of Városmajor did not fall apart with this change in leadership. The team stayed together, and continues to meet the professional, medical and economical challenges of the future.

In the mainstream of European vascular surgery Vascular surgery enjoyed undisturbed development under the direction of Professor Zoltán Szabó. This was a great accomplishment, because with the sudden death of Professor Soltész, vascular surgeons were not sure of the future. What will happen? We’ll surely have a cardiac surgeon director. What will he do with vascular surgery? Will this field be neglected? Along with doubt, hope was also there. A former cardiac surgeon, Professor Kudász, encouraged the first steps of vascular surgery. The staff members, whether they worked in the field of vascular or cardiac surgery, were still of the same Városmajor-family. Soon it became clear that the new leadership did not favor its own discipline alone, but respected all four the same: vascular and cardiac surgery, radiology and anesthesiology.

Professor Szabó also became director of the National Institute of Vascular Surgery, and president of the Professional Collegiate of Angiology. As such, he contributed much to the development of vascular surgery in Hungary. He went on many trips in the country with Professor Sándor Papp, director of the vascular surgery program at the clinic.

International relations Within a few years, the Városmajor Clinic became an outstanding cardiovascular center in Europe. Study trips abroad became more common, it was not considered a miracle any more if someone wrote an abstract for a conference held in the west, was accepted and could travel right away. Professor Szabó always encouraged these study trips.

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Dr. István Mogán received a year’s scholarship in Belgium, and became a department director upon returning. The great organizer of international relations was Dr. Csaba Dzsinich, who had excellent language skills, and many acquaintances. In the second half of the 1980’s, he organized the first Austrian-German-Hungarian vascular surgery conference on Castle Hill, where many were in attendance, both from home and abroad.

The presentations were followed by a dinner, where we were able to become better acquainted. Thus, we built relations with Graz, Wien, Innsbruck and Munnich, and were able to participate at Austrian and German conferences. When we were invited, we did not have to pay a participation fee, instead we received some “pocket money” from our well-to-do neighbors.

This is when we had the world-famous Professor Vollmar as our guest. He came with his angiologist colleague, the ever-elegant Professor Nobble. Upon listening to their presentations, it became clear to us that a vascular surgeon could not be successful without a cooperative angiologist. Dr. Csaba Dzsinich and Professor Szabó organized nice social programs as well.

New vascular surgery solutions Several new, smaller or larger case solutions were initiated during this era. As Dr. István Mogán learned in Liege, we started to use hooks in various operations, and the patients were happy, because the small holes were easier to heal.

From conferences abroad, we also brought home the use of peripheral bypass, along with in situ bypass. Dr. Csaba Dzsinich conducted several successful renal reconstructions, and taught these to the colleagues.

Aortic dissections were considered taboo in Hungary for some time. The first operation of this kind was conducted when Professor Soltész was still alive, and it was an outstanding example of interdisciplinary cooperation. The first team consisted of the Soltész-Szabó-Papp triad. Two dissection teams were also set up, with cardiac surgeon, vascular surgeon, anesthesiologist and radiologist members. In the 1980’s, we became more experienced in treating various kinds of dissections.

In the early 1990’s, a new surgery type, eversion endarterectomy, came from Nurnberg.

It was not all new, since M. DeBakey conducted the first carotid eversion in 1959, but due to lack of success, it was abandoned. The new method conducted eversion on the internal carotid artery, which is easy to mobilize, so the surgery became successful. This 130 Th e

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method shortened the operation time, and shunts were no longer needed. Dr. Sándor Papp listened to reports of the new method, and then said to his assistant during a carotid surgery: “come, show me what you can do”. This was exceptional, because great care was needed, due to the stroke-hazard. The operation went well, and the response was enthusiastic all through the country. Professor Papp always favored whatever proved to be good, even if a well established method had to be replaced in consequence. He was a brilliant surgeon, operating with both hands, and he was without envy, always open to new things. He pointed out the errors if he detected any, but praised the good. We greatly missed him after he left.

Departures and arrivals Dr. Péter Gloviczki, who worked at our clinic in the early 1980’s, turned toward a much neglected field of medicine: lymphatic vessel surgery. He worked on a new procedure, trying to connect the lymphatic vessels and the small veins. This research discontinued at his departure.

Others left the clinic as well, in search for a brighter future. Dr. László Molnár was a very promising vascular surgeon, but could not resist an attractive South-American offer.

Others came to us from abroad. Dr. Eberhardt Krause married here from East-Germany.

He was very talented, learned to speak Hungarian rather well, and had a good relationship with patients and colleagues alike. When we went to conferences in the “west”, that was first time for him as well. In 1981, he drove us to London us with his Lada 1500 car, and we stopped by Stuttgart for him to visit his cousin for the first time in his life.

Doctor Eberhardt would have stayed in Hungary, but his family affairs required him otherwise, and he did not return from Austria after a conference there. We had a lot of fun listening to him and our Georgian colleague, Gyuri Damenija, correct each others Hungarian expressions in the surgery room.

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The foundations of a new ars poetica Looking back, we can definitely say that the clinic gained strength in every way under the leadership of Professor Szabó. This is true for individual professions as well as the clinic as a whole, where a unified cardiovascular perspective became the norm, laying the foundations of a new ars poetica for the ensuing decades. In general, we can say that several surgery types became routine procedures in the 1980’s, superfluous movements were replaced with expedience, and operations once considered outstanding became commonplace.

During this era, we all started to feel the spirit of freedom, the world opened up in both professional and individual avenues. This freedom, however, installed a rather naive anticipation of miracles in most of us.

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Professions through time The essence of modern cardiovascular surgery: diagnostic imaging Changes in the role of cardiology are easy to trace in the clinic’s history, even though the first 65 years are for the most part lost to forgetfulness, due to lack of records. At the Kudász-Clinic, Dr. Gyula Kisvárdai and Dr. Iván Pénztáros served as radiologists. Their colleagues were highly satisfied with their work. They did not expand their classic role, however, and the technical part of invasive tests were done by surgeons and cardiologists.

After the death of Dr. Kisvárdai, Professor Soltész recognized the need for someone who was well immersed in diagnostic radiology. He chose Dr. László Szlávy, a renown specialist, associate professor at the Radiology Clinic, to head the Department of Radiology. Dr. Szlávy had been on extended study trips to Harvard University and to the Karolinska Institute, and he was the first to conduct coronarography in Hungary. Thus, he was a perfect choice for this important position.

When he became the director of radiology in 1978, there were two radiologists working beside him (Dr. Iván Pénztáros and Dr. László Entz). Angiography was done using outdated machines, and there was a fluoroscopic x-ray machine. Following the appointment of Dr. László Szlávy, however, the Radiology Department saw unprecedented development, receiving a new angiography machine in 1981. At the time, in 1983, we were the first in Hungary to use DSA (digital subtraction angiography) technique. Thus, we started using these techniques and tools even before several modern European universities.

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Interventional radiology and the first MR Along with invasive diagnosis, interventional radiology underwent spectacular changes as well. We were among the first in the world to use PTA balloons (percutaneous transluminal angioplasty) on the subclavian, the vertebral and the carotid artery. We were pioneers in the use of stents and in laser angioplasty. There were hardly any areas in interventional radiology, where Professor Szlávy did not move forward. He instituted isotopic diagnosis as well, but this method never prospered at our clinic, and the isotope laboratory was discontinued after 10 years of operation.

During the second part of the 1980’s, a high-standard radiology department with CT and MR machines was established in the new building at Határőr street 18. In 1986, there were three modern CT machines in Hungary, one was located in the Department of Cardiovascular Surgery. In the following year, an MR machine at this same location was the first of its kind behind the iron curtain in Europe.

The Central Radiology at Határőr street in construction in 1986

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…and the opening ceremony of the radiology department in 1986. Several professors and administration members in attendance

Since COCOM (Coordinating Committee for Multilateral Export Controls) was still in effect, we also had to get permission from American security offices to deploy an MR machine. The building itself received an architectural award for its high quality.

Along with the installation of new equipment, specialists were also trained. Dr. Kálmán Huttl, Dr. Imre Répa and Dr. Árpád Simonffy were already there, and Professor Szlávy invited renown Hungarian specialists and ambitious young colleagues to our institution: Dr. Béla Fornet, Dr. Kinga Karlinger, Dr. Györgyi Katona, Dr. György Várallyay, Dr. György Bindics, Dr. Ildikó Kalina, Dr. Árpád Baranyai, Dr. György Balázs, Dr. Zsuzsa Monostori, Dr. Gyula Horváth, Dr. Zsuzsanna Papp, later to be joined by Dr. Krisztina Urbanek, Dr. Zsuzsa Ördög, Dr. Mária Gődény, Dr. Zoltán Harkányi, Dr. Balázs Nemes, Dr. András Bolcsházi and Dr. Viktor Bérczi.

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Nurses at the Central Radiology in 1990

Central Diagnostic Radiology The years after 1986 constituted a golden age in Határőr street. We worked hard, and together we learned and taught a discipline that was totally unconventional in Hungary.

The best vascular surgeons, cardiac surgeons, neurologists and internal surgeons came to visit us, and the institution produced several doctors, x-ray surgery room personnel, as well as CT and MR operators who played a vital role in dispersing modern radiology tests throughout Hungary.

The institution on Határőr street was named Central Diagnostic Radiology, and at first it did not belong to the university, but to the Countrywide Vascular Surgery Institution, directed by the Ministry of Health.

Dr. Zoltán Szabó, university professor became the director, with Professor Szlávy as his assistant, who directed the day-to-day work. In 1991, at the request of both, the institution became independent, under the umbrella of the Semmelweis Medical University, and Professor Szlávy became the appointed director.

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At that time, only a small percentage of patients sent for CT and MR tests came from the Department of Cardiovascular Surgery, but the center received a great number of patients from all over the country, because for the first five years, it had the only MR machine in Hungary. As CT and MR tests became available elsewhere, the percentages changed.

The radiology unit of the Department of Cardiovascular Surgery, where interventions and traditional radiology took place, was a separate organization, but worked in unity with the center.

The era of technical relapse Sadly, the 1990’s were years of relapse Professor László Szlávy for the Határőr street institution, the developments did not keep up with the demands of the time. In 1996, the MR machine could not be repaired any more, and the laboratory was closed down for six years.

CT and MR restart efforts In 2000, after Professor Szlávy retired, the Senate decided to join the Central Radiology with the radiology unit of the Department of Cardiovascular Surgery, directed by Professor Attila Nemes, and appoint Kálmány Huttl to its head. Together they tried to replace the MR and CT equipment and restart these programs, but they did not have access to the necessary financial resources. During this period, the interventional department’s development remained stable.

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University in Boston. The well known Hungarian radiologist worked with the American General Electric and the Israelite Insightec companies in a research program to use MR tests in interventions. These companies had just developed an MR guided, focused ultrasound machine for clinical testing, and sold one to our institution at a very reasonable price we could afford to pay. Therefore, in September, 2002, we received a 1.5 Tesla MRI scanner, with an integral, focused ultrasound tumor treatment unit. This enabled us to move to the top in cardiac and vascular surgery testing. At the same time, Harvard University, Semmelweis University, and the Pannon Agronomics University signed a joint research contract.

Dr. György Balázs was appointed to direct the MR and CT departments. He had started his career here, and worked at Heim Pál Hospital between 1994 and 2002. Additionally, old and new radiologists alike, along with a new assistant, joined the team.

During these months new vascular testing techniques (such as MR-angiography) were introduced, several neuroradiology tests were conducted, and MR testing of cardiothoracic, as well as abdominal malformations became a daily routine, as Professor László Szlávy had once envisioned. The new machine also made cardiac MR testing possible.

The start of cardiac MR Although this test type became a clinical routine in the second half of the 1990’s, the first MR machine, in operation between 1987 and 1996, was not yet capable of carrying it out. In Hungary, it was Dr. Tamás Simor, a cardiologist professor from the town of Pécs, who first learned this technique in the USA, and he conducted cardiac MR testing at the Diagnosis Center of Kaposvár. He was the one who came to supervise this work at our institution. During the first few years, he spent all his Saturdays at the MR laboratory on Határőr street, where young radiologists and cardiologists, such as Dr. Hajnalka Vágó and Dr. Attila Tóth, learned the procedures under his direction, and then became world-famous specialists.

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The first cardiac CT, with ECG-gating Our institution was the first in Hungary to conduct cardiac CT with ECG-gating. This technique made coronary imaging possible without heart catheterization. The enthusiastic team included Dr. Kálmán Huttle, department head, Dr. Balázs Nemes and Dr. György Balázs, his assistant in invasive and non-invasive fields, as well as specialists, such as Dr. Györgyi Katona, Dr. Ildikó Kalina, Dr. Asztrid Apor, Dr. Árpád Simonffy, and Dr. Viktor Bérczi.

Within the framework of an international scientific cooperation agreement, we conducted uterine myoma treatments, and several dozens of patients enjoyed the benefits of this new procedure, which effectively dispersed their complaints without surgical intervention. Unfortunately, the procedure was very time-consuming, and the working capacity of the MR laboratory was limited, so this project did not develop as much as it could have without these constraints.

The arrival of the 21st century for good In 2005, the university installed a picture archiving and communication system (PACS), highly beneficial for Városmajor, where thousands of CT, MR, ultrasound and catheterbased images were stored daily. The whole internal scene of the institution changed, computer screens became commonplace everywhere. The digital radiology era of the 21st century arrived.

Between 2006 and 2007, the head of our department, Professor Kálmán Huttl, served as institution director of the university’s Radiology Clinic as well.

Structural changes in Városmajor between 2008 and 2012 united the Diagnostic Imaging Department with the newly established Cardiology Center, directed by Professor Béla Merkely. Major developments were initiated, focusing on the needs of cardiology and cardiac imaging.

Even though both the MR and the CT machines were rather new, additional equipment was needed for modern cardiology tests. In September of 2008, a new Philips 1.5 Tesla MRI scanner, and in November of 2010, a Philips CT 256 slice scanner was installed. The new technology made it possible to restructure the patient care workload, and 40-50% of the MR laboratory time is now used for cardiac tests. The new CT provided details never before seen in coronary images, and since none of the other hospitals in 139 Th e

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Budapest had this advantage, we conducted a great number of CT tests on a daily basis after the installation – over 1000 during the first year.

Dr. Pál Maurovich Horvát, a young cardiologist, studied this procedure in Boston for three years, and then returned in 2010, ensuring that we implement it with high fidelity and exactness.

The renewed Diagnostic Imaging Department Along with getting new technical equipment, the facilities of the building on Határőr street were rearranged as well. The CT laboratory moved into the basement, and five patient examination rooms were installed on the ground floor.

In between 2008 and 2012, several cardiologists and young, talented entrants joined the diagnostic imaging team: Dr. Kálmány Huttl, Dr. György Balázs, Dr. Balázs Nemes,

To move the MRI machine, we not only needed cooperation and heavy lifting equipment, but we had to break through the wall as well.

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Dr. Györgyi Katona, Dr. Árpád Simonffy, Dr. Andrea Varga, Dr. Edit Dósa, Dr. Attila Tóth, Dr. Hajnalka Vágó, Dr. Nándor Pintér, Dr. Pál Maurovich Horvát specialists, Dr. László Szidonya, Dr. Csaba Csobay Novák, Dr. Hunor Sarkadi, Dr. Slavka Kudrnova, Dr. Andrea Bartykowszki, Dr. Mihály Károlyi, Dr. Péter Takács specialist candidates, PhD students, as well as colleagues working elsewhere: Dr. Tamás Simon, Dr. Péter Barsi, Dr. Gábor Tóth, Dr. Attila Doros, and Dr. Zoltán Pozsonyi.

The invasive and interventional radiology department also experienced stable development during the last 30 years. Excellent surgery room and x-ray assistants came to help the core team: Dr. Kálmán Huttl, Dr. Balázs Nemes, Dr. Árpád Simonffy and Dr. Edit Dósa, as well as other young people, who benefited by getting experience under their direction. They have an excellent laboratory, where several special interventions were initiated. Their staff is available around the clock, not only for their own institution, but for other hospitals as well. The last few decades saw many cases when they were able to stabilize a patient with heavy bleeding or extended venous thrombosis with embolotherapy or stent implantation.

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“I am convinced that balance in economics – this is my unique thesis – can only be reached through innovation.”

(Quote from an interview volume written

by Prof. Dr. Attila Nemes: “Titoknyitogató”)

New approaches in demand Department of Cardiovascular Surgery (1992–2003) Prof. Dr. Attila Nemes was born in Budapest, on November 30th, 1938. He finished the József Attila Highschool in 1957, and graduated from the General Medicine Department of the Budapest Medical University in 1963. He completed a specialty exam of surgery in 1968, of cardiothoracic surgery in 1970, and of vascular surgery in 1980. He holds a candidate’s degree in medical science since 1972 (termed a PhD degree in 1993), and a DSc in medicine since 1998. In 1990, he was appointed a university professor. He was director of the Department of Cardiovascular Surgery at the Semmelweis Medical University between 1992 and 2003, and vice president of the Semmelweis Medical University between 1991 and 1994.

He was president of the Hungarian Society of Angiology and Vascular Surgery (19972001), member of the Professional Collegiate of Surgery (1998-2005), president of the Professional Collegiate of Angiology (1992-2005), board member of the Hungarian Society of Surgeons (1998-2009), president of MOTESZ, the Association of Hungarian Medical Societies (2000-2002), president of the Budapest Medical Chamber (2006145 Th e

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2007), and member of the Hungarian Accreditation Committee (1997-2001). He received the Lajos Soltész Medallion (1997), the Commander’s Cross in the Order of Merit of the Republic of Hungary (1998), the János Balassa Medallion (2000), the Semmelweis Medallion (2001), the László Batthyanyi-Strattmann award (2003), the Markusovszky award (2005), the Budapest Technical University Medallion (2005) and the Hippokratesz Medallion, among other awards and rewards. He has 300 publications, wrote 13 books and 34 book chapters. He is a juridical expert since July 2003, and professor emeritus since July 2008.

The first Hungarian heart transplantation took place on January 3rd, 1992, under the direction of Professor Zoltán Szabó, who was celebrated by colleagues and the general public alike as one who made it to the top in his career as a cardiac surgeon and a clinic director. One month after this outstanding event, he surprised everyone by announcing his withdrawal from directorship of the Semmelweis Medical University’s Department of Cardiovascular Surgery, even though he still had two years left from his mandate. As of February 1st, 1992, the university board appointed Professor Attila Nemes, a vascular surgeon, to direct the clinic. On July 1st, 1992, he received his university professorship as head of the department, and a new era, lasting for eleven years, started in the life of the clinic.

The new director had a picture in his room, given to him by his predecessor, with this inscription: “Watch the fire and the flood!” The task was enormous: keep the clinic’s leading role in the field of cardiovascular surgery, and find new approaches to secure steady development without a clash of individual ambitions. Just like Professor Zoltán Szabó, Professor Attila Nemes also knew that the clinic’s stability required broad foundations.

Life after communism, the change of the system Rapid changes in political and economic circumstances had to be balanced out to reach success in the work. These changes started even before the fall of the communist system, and Professor Attila Nemes facilitated smooth and effective transitions both for the university and for the clinic.

Professor Nemes, as board member, and Dr. Miklós Réthelyi, as vice president, were the ones to form the new university structure. The early 1990’s were critical times, with 146 Th e

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high tempers. Traditional values had to be preserved, but new demands had to be met – using the old structures, but on new avenues, pursuing new goals.

Heated discussions were conducted not only with the former leadership of the university, but also with the invigorating student representation. At the end of communism, the need for democracy arose. Yet, the fine line between dictatorship and anarchy is not that easy to establish. Professor Nemes directed the development of a new charter for the Semmelweis Medical University.

Apart from general organization, Professor Nemes also contributed to the establishment of several new university institutions and programs, such as the Student’s Center, the Health Manager Center and the Family Doctor Department, as well as the Tempus Program.

“Discipline is essential at a surgery department” It was natural to follow in the footsteps of Professor Zoltán Szabó, but this had to be done with an eye on the challenges of the times, and in line with the character of the new leader. The new professor favored democratic principles, but only with appropriate controls. “I believe surgery is almost like a militant group, where some things can go democratic, but others have to be carried out by command, for the good of the patients. In other words: discipline is essential at a surgery department.” Right from the start, he held the decisionmaking ability of the Institutional Council in great esteem. He also believed that community interest preceded individual interests, that the clinic had to pursue the goals of a community, and not individual ambitions. Thus, in his book (Prof. Dr. Attila Nemes, Titoknyitogató), he quoted this phrase from Kennedy: “my fellow Americans: ask not what your country can do for you – ask what you can do for your country.”

Technological revolution – new challenges The years around 1992, when Professor Nemes became director, were revolutionary years both in vascular and in cardiac surgery techniques. There were open surgeries, as well as catheter-based interventions. The tendency was to favor minimally invasive, laparoscopic procedures in abdominal surgery, and endovascular methods in cardiovascular surgery.

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The challenge was to restructure the clinic to meet these new demands, and at the same time keep the old values of the prestigious institution. New programs were needed in the field of peripheral and unique cardiac interventions. Professor László Szlávy, the pioneer of Hungarian radiology, established the country’s first catheterization laboratory at the Department of Cardiovascular Surgery. He conducted the first coronarographies, and established several interventional procedures. In comparison to today’s quantities, the case numbers were low, and the technical support wasn’t ideal, either. However, the pioneers were enthusiastic: Dr. Tibor Vécsey at the hemodynamics laboratory, Dr. Kálmán Huttl at the peripheral angiography laboratory, Dr. Gábor Kerkovits in the ultrasound laboratory, Dr. Béla Merkely at the electrophysiological laboratory, each surrounded with several young doctors and assistants, often working into the night, establishing the foundations of complex internal medicine, endovascular and surgical care. Changes in international trends and domestic demand made it necessary to expand the endovascular capacity of Városmajor, where everything was available to do so. Development was apparent in all disciplines at the clinic.

Cardiac surgery – steady development Opportunities and professional challenges are good indicators of how well the practical side of medical science progresses. From this perspective, this era was the golden age of cardiac surgery. The pioneer predecessors laid a firm foundation, and interventions once considered heroic became routine operations. The results were also good, the yearly mortality rate stayed around 3%, below the European average. Collaboration was an integral part of success, decisions were made in council, and even the surgery assistants were well informed and experienced. Considering all involved, the experience gained in 100-120 years of surgical procedures led to the right solutions in hard situations.

The number of surgeries did not always mirror the potential capacity of surgeons.

Even though the tendency was positive, the 600-some extra-corporal surgery number was less than the team was able to handle. Machinery breakdown, intermittent lack of tools, and the small capacity of the intensive care unit were to blame for the limitations.

Nevertheless, all urgent interventions were done in time, the clinic was able to handle all patients within its jurisdiction, and served as a countrywide center for complex and large vascular surgery catastrophes.

Along with routine interventions, new surgery methods were established as well. Pro148 Th e

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The academic staff of the clinic in 2003

fessor Elek Bodor directed the expansion of the heart transplantation program once initiated by Professor Zoltán Szabó. Several stumbling-blocks were identified, and both the early and the later results improved. The experience gained during this era laid the foundation of today’s accomplishments. With mortality rate under 10%, and the 60% survival for over 10 years, the clinic was matching the results of European centers that had much more experience with these methods.

The surgical treatment of complex arterial deformations is a renown tradition of our clinic, requiring the cooperation of vascular and cardiac surgeons, as well as invasive radiologists. We serve as a countrywide center for aortic aneurysm and extensive aortic dissection. With raising case numbers, it became evident that several Marfan syndrome patients needed not only acute surgeries, but preventive interventions as well, along with early recognition and close follow up. This work is carried out by the Marfan working group, with Dr. Zoltán Szabolcs at the head. We have about 300 registered patients, and conducted 112 surgeries, now most of them preventive, which led to wonderful results in the mortality rate.

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Homograft bank – the base of infection treatment Even with continual development in surgery techniques, the treatment of infections, during or after the intervention, have always presented a great risk. Professor Attila Nemes commissioned Dr. Tivadar Huttl to oversee the formation of a homograft bank, which serves – in its modern form – as the chief base for septal cardiovascular surgery to this day. We stored the cardiac valves and vein sections taken first from cadavers, then from transplantation donors in nitrogen storage containers brought from the Gottsegen György Countrywide Cardiology Institution.

In ischaemic heart disease, the use of arterial grafts turned out to be the key factor in long-term functioning. New solutions were applied in post heart attack aneurysms as well, with the help of modern diagnostic procedures.

The birth of the Cardiovascular Center We witnessed accelerating progress in cardiology as well, with ever-growing number of interventions both in hemodynamics and in electrophysiology. The angiography equipment and the number of post-surgery hospital beds could not keep up with this progress.

The need arose for a myocardial infarction center, serving patients in the Budapest region around the clock.

The university and the clinic could not keep its leading role and provide sufficient invasive cardiology care without infrastructural enlargement. Professor Attila Nemes initiated negotiations with the Ministry of Health, and was appointed to oversee the professional and economic aspects of the new Cardiovascular Center (CVC).

Dr. József Finta, a prominent Hungarian architect, drew up the plans pro bono, and helped the construction all through its completion. Professor Nemes and his cardiologist colleagues, such as Dr. Béla Merkely, became overseers and quality controllers at the construction for a year.

They walked through the construction site every day, participated in weekly construction meetings, and – according to Professor Nemes – became well immersed in statics, architecture, engineering, and other specializations. The cornerstone was laid in February of 2002, with Dr. István Mikola, health minister, presiding at the ceremony, and within ten short months, on January 10th, 2003, the under-secretary Dr. Mihály Kökény presided 150 Th e

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The cornerstone ceremony in 2002. Dr. István Mikola from the Ministry of Health did not just talk, but did much to help as well. Next to him, from left to right: Dr. Péter Sótonyi, president, Professor Attila Nemes, and Dr. Béla Merkely, director of the new division

at the opening ceremony. Professor Nemes said at this occasion: “Even in a world full of fractions, we can bridge the gaps for a good cause”. The new center, where Dr. Béla Merkely became the section director, offered 24-hour acute myocardial infarction care.

The university’s president was Dr. Péter Sótonyi at the time, who said the following about the event: “February 22nd, 2002, witnessed a historic event at the Semmelweis University’s Department of Cardiovascular Surgery – the cornerstone ceremony of the new Cardiovascular Center. Dr. István Mikola, health minister, delivered a speech, in which he stated that invasive cardiology care was a priority. Dr. Attila Nemes delivered a ‘message to the future’, the text of which was placed into the cornerstone time capsule. Dr. Attila Nemes and Dr. Béla Merkely organized the event, and the participants were appreciative of their work. On January 10th, 2003, the opening ceremony was held. The new facility offered 1408 m2 net space on 3 levels.”

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In part for his merits in overseeing the construction of the Cardiovascular Center, Professor Attila Nemes received an honorary citizenship title from the 12th district of Budapest. Presentations held on this occasion revealed that the center he had envisioned did speed up the development of invasive cardiology. Back in 2002, there were 682 percutaneous coronary interventions, but this number grew to 1969 by 2004, In 2002, 600 pacemakers were implanted, and in 2004, this number reached 900. During this two-year period, the number of radio-frequency ablations grew from 71 to 203.

The Department of Cardiovascular Surgery now had a new facility, fit for new challenges, fulfilling all expectations.

Radiology: purchase and refurbishment Even though a separate section deals with the history of radiology, we wish to say a few words about the development of non-invasive imaging techniques. Since the clinic became a center, more patients arrived, requiring complex care. Apart from routine procedures, high-tech radiology background was needed for intricate therapy plans. Under the direc-

Press conference at the grand opening of the Cardiovascular Center. From left to right: Dr. Béla Merkely, Dr. József Finta, president Dr. Péter Sótonyi, under-secretary Dr. Mihály Kökény, and Professor Attila Nemes

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torship of Professor Nemes, the CT and MR machines were replaced, providing more detailed images on the peripheral veins and brain blood circulation problems.

Additional ultrasound machines were purchased. Both the hemodynamic and the peripheral angiography laboratory were refurbished.

Vascular surgery – the first stent graft In vascular surgery, the clinic was ranked at the top. There was remarkable growth in the number of venous reconstructive surgeries. 11 368 vein reconstructions took place between 1992 and 1999, five thousand more than during the previous eight years.

Almost all thoracic and thoracoabdominal aortic aneurysms and dissections were treated in our institution only. Professor Csaba Dzsinich was influential in establishing and developing various surgery techniques, and received several international recognitions for his work. By 1998, the number of carotid reconstructions exceeded 700, and from 2000, the proportion of carotid angioplasty procedures grew as well. A change of paradigm was fast approaching in vascular surgery. Percutaneous and hybrid operations became more and more commonplace. Instrumental developments brought better and better results in peripheral angioplasty and stent implantations.

In 1986, Volodos from the Ukraine conducted the first made in Hungary stent graft implantation on a patient with high-risk aortic aneurysm. The new procedure was reported in Russian only, so it only received worldwide recognition in 1990, when Dr. Parodi conducted the first abdominal stent graft implantation, and the report appeared in a prestigious periodical. In 1992, Dr. Dake followed him with the first thoracic aortic stent graft implantation (reported in the New England Journal of Medicine in 1994).

FDA, the U.S. Consumer Protection Agency did not permit abdominal stent graft implants until 1999, and thoracic ones until 2000.

In Hungary, Professor Attila Nemes pushed for the procedure’s acceptance and financing. The first Hungarian stent graft implantation took place on the abdominal aorta, in 1998, by Dr. Lajos Mátyás in the city of Miskolc. The first Hungarian thoracic stent graft implantation was conducted in 2000, by Professor Attila Nemes and Dr. Kálmán Huttl, with the help of renown specialists from abroad, at the Department of Cardiovascular Surgery. The stent graft program soon became well established at our clinic, as well as in the other two centers in Hungary. The vascular surgery room received a new and mobile DSA machine, and the vascular surgeons, radiologists and anesthesiologists learned the 153 Th e

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peculiarities of the procedure. Now the only barrier to stent graft implantation is formed by financial constraints.

The young girl who received the first stent graft, due to a traumatic thoracic aneurysm, later became a medical student and wrote an award winning paper on the use of stent grafts at our clinic.

The number of iliofemoral hybrid procedures, and hybrid procedures on the femoral artery also grew, gradually. Dr. György Acsady played a vital role in introducing deep vein reconstructive surgery procedures.

Until 2005. Professor Nemes directed not only the clinic, but the Countrywide Vascular Surgery Institution as well. His task was to oversee and evaluate vascular surgery activities in Hungary.

Basic and postgraduate training The clinic played an active role in Hungarian specialist doctor training. Specialist doctor candidates spent shorter or longer periods at our clinic, depending on the vascular surgery program of their base institution.

Between 1980 and 2010, our clinic was the only place where specialty board exams were conducted. In 1992, the vascular surgery division of UEMS Section of General Surgery was established in Edinburgh to harmonize vascular surgery training in Europe, and Professor Nemes played a vital role in the preparations. Starting in 1994, Professor Nemes served as course director in biomedical engineering at the Budapest Technical University, opening doors to interdisciplinary cooperation.

Colleagues at the clinic not only participated in Hungarian postgraduate medial training, but also held several successful presentations at European vascular surgery conferences. The 12th European Congress of the International Union of Phlebology was held in Budapest in 1993 (Professor Acsády organized the event), and the 50th Congress of the European Society for Cardiovascular Surgery in 2001 was also held in Budapest, organized by Professor Dzsinich, then president of the prestigious society.

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Goals turned into results The period between 1992 and 2003 could be described as the Belle Époque in the history of the clinic. A good number of renown specialists started their career during these years, and several new procedures were established (coronary and venous interventions, pacemaker and stent graft implantations), some of which are routine interventions today, and make our clinic all the more effective. Our profession is not competitive, but complementary, and if cardiologists, radiologists, anesthesiologists, surgeons and others work together well, then with proper tools, the realistic goals turn into results.

Professor Attila Nemes summarized his directorship this way at his last institutional council meeting: “June 6th, 2003. Clean-up Friday. No surgery. Today, for the last time, Attila Nemes conducts the institutional council meeting. In attendance: Elek Bodor N.A., György Acsády (only at the beginning), Zoltán Szabolcs, Kálmán Hüttl, Béla Merkely, László Entz, Katalin Széphelyi, Katalin Pápai, Eszter Nagyné, Arthur Moldoványi, Péter Kovács. Absent: Csaba Dzsinich.

Attila Nemes listed notable events of the last 12 years, under his directorship: 2 CD, MR machines, 3 DSA machines, the Cardiovascular Center, corridor, angioscope, 1 surgery table, regular cleanup and coating, 2 anesthetic machines, monitors, homograft bank, clinical use of stent grafts, etc. In 1999, the clinic had 300 million HUF debt, By 2000, it was almost balanced out. In 2001, there was some profit already, in 2002, the profit was 300 million HUF (hemodynamics brought the money), and by the end of April 2003, the profit reached 400 million HUF, making it possible to purchase a new spire CT to replace the broken one.

He accounted for the assets of the Foundation (about 30 million HUF current), and commented on the democratic leadership of the institution, with the help of the same colleagues, under his directorship.”. (Zoltan Szabolcs: Journal excerpt.)

It seems symbolic that an important event took place on the last workday of Professor Nemes. On June 30th, 2003, the DSA laboratory was opened, making it possible to conduct cardiac and peripheral vein interventions.

My colleagues wrote magnificent things about me, which seems rather boastful to me. All in all, the stories about the distinct eras always reveal some of the blunders as well. Since I am the main character in this one, let me relate an awkward story about myself: 155 Th e

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“We became world-class in this small Central-European country” Interview with Professor Csaba Dzsinich, who worked at the Vascular Surgery Department of Városmajor for almost 40 years, and established several new procedure You got to Városmajor in 1969, but because of your father, you have earlier memories from the institution, and heard about what János Sanatorium was like back then.

Yes, my father graduated from the medical faculty of Pázmány Péter University, and got to work at the 1st Internal Surgery Clinic as a young doctor.

As a so-called unpaid teacher assistant, he did not get any salary, so he had to work as physician in attendance in Városmajor, then called János Sanatorium, directed

by Humer Hultl. From what my father said, Humer Hultl was highly collegial with the young ones. Once he led my father into his prestigious office on the first (Photo: AtteKovacs) floor, and said: “Dear young friend, satiate yourself with my drinks and cigars!” My father thought back on this conversation as a dear memory, and remembered the mentality of the old János Sanatorium with much love. It accommodated 40 patients, had beautiful art nouveau copper beds, and the apartments were so elegant that servants ushered in the visiting doctors.

Your father was a cardiologist. When did you decide not to follow in his footsteps, but become a surgeon?

I enrolled at the Budapest Medical University in 1961, and made that decision rather early, during my anatomy studies. I had to conduct a brain dissection at a practical exam, where Professor Donáth was presiding, and he said: “Son, you have skilful hands, 156 Th e

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why don’t you become a surgeon.” So that was one side of the story, and the other side was the fact that it is always hard to follow in the footsteps of progenitors. I wanted to follow a slightly different path from my father. And since I was preparing to become a surgeon almost right from the start, I went to work as physician in attendance at the 4th Surgery Clinic.

Yet you did not start your career at Városmajor right after the university, why?

I wanted to, but Professor Kudász had high expectations, he barely ever admitted anyone right after graduation. He told me to spend a few years in other disciplines. Since I was a good student, I won an academic scholarship and worked at the laboratory of Professor Dezső Szabó for two years, studying electromicroscopic histology. I came to love it, and had another scholarship lined up in Canada, but Professor Kudász sent word: “Son, I have your place”, and on December 15th, 1969, a snowy winter day, I reported at Városmajor. The clinic was a wonderful institution and a great place of learning, because you had to spend some time at each department: general-, cardiac-, cardiothoracic- and vascular surgery. I worked with cardiac surgeons first, then with Professor Besznyák at cardiothoracic surgery, with Sándor Dorobni at the general surgery department. In 1972, I passed my specialty board exam in general surgery, and faced the great dilemma – which way to go. Both the cardiac surgeons, and Professor Soltész from vascular surgery invited me to join them, and I decided on the latter. Imre Szabó and Sándor Papp were my immediate supervisors, and I was very enthusiastic about learning the profession, which, we have to admit, was just developing in the late 60’s and early ‘70-s, with rather limited technical possibilities.

The development of vascular surgery is considered to have taken place after the second world war on an international level. How much were you able to follow the international trends at the clinic?

Very few could travel abroad. Professor Soltész and then Sándor Papp went on short study trips to France, and brought the first pieces of information home. We tried to read the periodicals, did our own angiography, worked with handmade instruments, and did not have international relations.

But then a great turn of events took place…

In the early 1970’s, we constantly applied for scholarships abroad with more experienced colleagues, but nothing happened. Some of my older colleagues gave it up, but I kept 157 Th e

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trying. Here I have to make a detour in the story. The director of the intensive care unit held a prominent position in the communist party. This brought substantial support to our clinic in the political situation of the time, but right at start I had a conflict with him.

At a night shift, I had to operate on an old man, a tailor, because he got so discouraged about his amputation that he cut into his veins. I rushed him into the surgery room, stitched his veins and took him into the intensive care unit. Within 10 minutes, the head of anesthesiology called and ordered me to move the patient. I declined to obey, because I was convinced that he had to stay there. From that time on, this director wouldn’t even reply to my greeting, and I was very much afraid that this could cost me my job. Coming back to the original story line, I got a call from the university president’s office, that my application was forwarded to the scholarship board, which belonged to the ministry of home affairs. I got into my car right away and drove to the board’s office to see what I could do. The head of the board was an internal affairs colonel, the lord of life and death in this field. At the office, the secretary was upset that I came, but when the person who was head of the board heard that I was there, he called out: “Comrade Dzsinich, come in!” Then he said: “Comrade Dzsinich, we know all about you. Do you remember that old man, uncle Forrás?” Of course I do, I said, I had been worried for two years now that I would be fired from the clinic because of him. As it turned out, this man served together with the three sons of uncle Forrás as a soldier, and uncle Forrás was the man who cut his veins, and whom I operated. I then became the first vein surgeon to receive a Humboldt scholarship, and was able to work at the University of Munich, then considered the citadel of vascular surgery, for two years. This was a great turning point in my life, and I am not boasting to say that in the history of the clinic as well.

What did you learn on this study trip that you were then able to use at the clinic?

I became acquainted with the full range of modern vascular surgery techniques. Pretty much during the same time, Péter Gloviczki got a scholarship in Paris, and Attila Nemes made it to Helsinki. We all came home with new knowledge, and this initiated fastpaced development for the clinic. It was also an important factor that the clinic became a countrywide institution under the directorship of Lajos Soltész, which meant that Városmajor coordinated all vascular surgery care and training throughout the country.

Since I had German acquaintances, I started organizing international affairs, and in 1982, German colleagues came for a vascular surgery symposium held in German (this we organize every other year since). Also, five of us were able to attend the Austrian Vascular Surgery Congress.

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Professor Soltész was already ill at the time, and passed away a few months later. You got a cardiac surgeon as head of the clinic, Zoltán Szabó. What was your reaction as a vascular surgeon?

First we were were afraid of having a cardiac surgeon as director, who would then supervise vascular surgery as well, but Zoltán Szabó not only supported vascular surgery, but greatly helped to move it forward. The institution became a Central-European training center, several colleagues from neighboring countries came to learn.

Was this enhanced with the end of communism?

In 1980, I was the first in Hungary to operate thoracoabdominal aneurysm, in 1984, aortic aneurysm, and in 1985, long aortic dissection. With background research on this special field, we had spectacular accomplishments. Maybe the timing wasn’t all that optimal, because I did not take part in the stormy rearrangement of positions when the system changed.

Then, when university realignments took place in 2007, and the State Health Center was opened, they asked me to establish a European-level Vascular Surgery Center. I agreed, and left the clinic after 38 years of working there – which time period I recall with much love, gratitude and pride, because in a small Central-European land, it offered a professional atmosphere and spirit you can only find in the largest and best West-European institutions.

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The expansion of cardiovascular medicine – modern cardiology, and minimal invasive therapy comes to the forefront Cardiology Center, Heart Surgery Clinic, Vascular Surgery Clinic (2003–2012) At Semmelweis University, cardiology care, training and research belonged to internal medicine clinics and programs only. Yet the rapid development of cardiology diagnosis and therapy, as well as the high number of patients called for institutions offering complex cardiology treatment. The first center of this kind was established by the Ministry of Health on Haller street, and the Cardiology Department of Semmelweis University was moved to this place, under the directorship of Professor György Gottsegen.

Cardiology Department on Haller street Professor György Gábor followed him in the director’s chair, and under his supervision, a new facility, built to this purpose, was opened in 1976. It was named Gottsegen György Countrywide Cardiology Institution. The next director was Professor Tibor Romoda, who initiated the first hemodynamic tests in Hungary, which at the time were not restricted to the coronaries only, but since they did not have other means of diagnostic imaging, monitored the functioning of both heart chambers.

Professor Attila Árvay was the one who initiated a holistic approach in cardiac surgery and cardiology care. He was director for a long time, and raised both the countrywide 163 Th e

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institution and the department to European standards. He was followed by the children’s cardiac surgeon Professor Károly Lozsadi, who established the Children’s Heart Center.

Then after a short break, Professor Mátyás Keltai became director of the Cardiology Department.

Up to this point, the history of the Cardiology Department was related to Haller street on the Pest side of the Danube. 2007, however, became a turning point. Dr. Béla Merkely, university adjunct professor was appointed to direct the Cardiology Department, and he moved the program to Városmajor. The question arises: what prompted this turn of events?

A young genius Professor Zoltán Szabó often related that as director of the Városmajor Clinic, and president of the university’s General Medicine Faculty, he used to give a tea party to students returning from Heidelberg. On one such occasion, he noticed an outstanding young student, Béla Merkely. Upon talking with him and sensing both his leadership and his intellectual abilities, he invited him to work at Városmajor upon graduating. Professor Szabó felt he would be one who could lay the foundations of modern cardiology. Circumstances changed, and Professor Szabó couldn’t realize his plan, but passed on his recommendation to the dean of the university, Dr. Attila Fonyó. With his help, Dr. Béla Merkely went to Városmajor upon graduating, and did all that Professor Zoltán Szabó hoped for.

A new center is born Cardiology care has long established traditions in Városmajor, and traces of invasive cardiology can be found in its history as well. Dr. Béla Merkely, who worked as associate professor at the Department of Cardiovascular Surgery at the time, was instrumental in establishing the cardiology program. All along, he was already dreaming of a new, modern, European-level cardiology center.

As the previous chapter already stated, the Cardiovascular Center was built within eight short months. Those who envisioned this well equipped, modern center, also saw the structure of a heart center that matched the European practice of a holistic approach.

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The “dream team” The young specialists, who provided cardiology care under the direction of Dr. Mekely in the Cardiovascular Center, came from the clinic’s Research Laboratory, from the PhD program directed by Professor Sándor Juhász-Nagy for the most part. The professor, who drew so many of the youth into his circles, said the following: “The relationship between teacher and student is a dynamic and progressive one. At least it should be so… The student should not just rehearse what the master had said, and he should not be cast out for stepping a bit out of line… I am a researcher, but I’m interested in healing as well… Most of my students, those who do scientific work with me, become doctors, not researchers. They step out of our joint work’s framework…, and may unconsciously carry on some of its principles. I consider this a special kind of spiritual survival.”

Students of Professor Sándor Juhász-Nagy included Dr. László Gellér, who now stands at the head of the electrophysiology laboratory as an internationally renown specialist; Dr. Endre Zima, now assistant director at the Department of Invasive Cardiology as a

The Gaál street facade of the Cardiovascular Center under construction in 2002

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The front of the Cardiovascular Center in 2012

university adjunct; as well as other beloved students, such as Dr. Orsolya Kiss, Dr. Andrea Nagy, Dr. Andrea Szűcs, Dr. Hajnalka Vágó, Dr. Pál Maurovicsh Horvát, Dr. Pál Soós, and Dr. Szabolcs Szilágyi. The professor held Dr. Béla Merkely in high esteem, as a letter to the university’s president attests from 2006.

These enthusiastic young colleagues face today’s challenges with high expectations and perseverance both in clinical care, in teaching and in research. They think back of their master, Professor Sándor Juhász-Nagy with gratitude and tenderness. He was an example of high standard scientific research, integrity, helpfulness and love.

In 2001-2003, several renown cardiologists joined the doctoral staff at the Cardiovascular Center, including excellent hemodynamics specialists, Dr. György Szabó, and then the present assistant director, Dr. Dávid Becker, as well as former doctors of the clinic: Dr. Elektra Barthe, Dr. Astrid Apor and Dr. Ibolya Marozsán.

Professor László Selmeci, director of the clinic’s central laboratory, constantly sought to help the Cardiovascular Center’s work in the field of healing, teaching and research.

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Co-operation for the patients The new building offered a full spectrum of non-surgical cardiology care. The Cardiovascular Center had 15 intensive care and 12 cardiology beds to start with. Modern intensive cardiology care equipment was available too, including three ventricular assist devices for catheterization, an intra aortic balloon pump, and three respirator machines. First there was only one table for catheter-based interventions, but an expansion in July of 2003 made it possible to treat patients with two invasive coronary catheterization devices.

Effective acute care led to a 60% improvement in the mortality rate of high-risk heart attack patients, both while at the clinic, within 30 days, and within one year. The new unit beProfessor Sándor Juhászcame Hungary’s number one cardiology center, conducting the Nagy highest number of catheter-based percutaneous interventions, pacemaker and defibrillator implantations, as well as device-based heart failure treatments. The background of high-paced interventional care was provided by the brand new intensive care unit, directed by a few, now well known specialists.

Mutual fight against heart attack Acute cardiology care commenced at the Városmajor Clinic of Semmelweis University in January 2003, and this coincided with the organization of ST elevation heart attack duty watch in central Hungary. The circle of patients continued to enlarge, since it came to include high-risk, non ST elevation cases as well. This network type of care, provided jointly with the Gottsegen György Countrywide Cardiology Institution, and then with other hospitals, serves three million people in the region, with 24-hour access to immediate heart catheterization in case of a heart attack. About twenty thousand patients have been served this way. This type of treatment leads to very good mortality rate results.

Thanks to this service, now extended to cover the whole country, the number of people dying from a heart attack dropped to 7500 in 2010, half of what this number was a decade ago. Dr. Béla Merkely, then as overseeing specialist, played a key role in the es167 Th e

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The letter of Professor Sándor Juhász-Nagy to the university’s president, Dr. Tivadar Tulassay, in 2006

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The Cardiology Center – the academic staff of the Cardiology Department in 2011

tablishment and ongoing development of the system. When he was elected to be president of the Professional Collegiate of Cardiology, he withdrew from the overseeing specialist position, turning it over to Dr. Dávid Becker.

With unceasing hard work, as well as regular professional and social events, we got to the point that close to 80% of Hungarian STelevation heart attack patients receive this service. This result is among the best in Europe.

The era of ongoing structural changes Dr. György Acsady, vascular surgeon professor became director of the Department of Cardiovascular Surgery in July of 2003. The first four years of the Cardiovascular Center focused on patient care and research. Then, with only three months of preparation, on

The glass facade of the Cardiovascular Center from the yard

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The cardiac intensive care unit in the Cardiovascular Center

October 1st, 2007, it was renamed Cardiology Center – Department of Cardiology at the Semmelweis University, and became an independent university unit, offering patient care, training and research. Cardiovascular surgery, under the direction of Professor György Acsady, continued under the name of the Department of Cardiovascular Surgery. In 2009, the surgery programs were further divided, Professor György Acsady became head of the Vascular Surgery Clinic, and Professor Ferenc Horkay got to lead the Cardiac Surgery Clinic. At the same time, Professor János Gál established a Central Anesthesiology and Intensive Therapy Service Department in the Városmajor Clinical block.

In time, however, a holistic approach to cardiovascular care received general recognition, and the independent surgery and non-surgery programs were reunited to form the Városmajor Heart Center in 2012. The director became Professor Béla Merkely.

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Teaching the future generation The establishment of the university’s Cardiology Department in 2007 made it necessary to organize cardiology training in graduate education. This was a substantial task, since not only Hungarian, but English and German speaking students were involved as well.

The Cardiovascular Center and the Cardiovascular Diagnosis Center on Határőr street provided background cardiology patient care for the education program. The practical training included bedside check-ups and ECG analysis, along with becoming familiar with invasive and non-invasive imaging procedures.

In undergraduate education, a “Day of Cardiology” is held each semester – in Hungarian, English and German –, when students can register to participate in interactive lectures, resuscitation practice, ECG training, and all kinds of other activities related to patient care. The students are enthusiastic, regardless of initial hardships – as in 2010, when they had to be taken to a separate location by a rented bus, because the local CT machine wasn’t working yet.

Professor Béla Merkely and his team in treating an acute heart attack patient in the heart catheterization laboratory

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The undergraduate curriculum includes a practical class, very popular among the students, entitled “ECG in theory and by the bedside”, held in the evening hours, with the participation of almost all teachers at the clinic. The Scientific Students’ Association is very active in teaching and in conference participation.

The journal entitled “Orvosképzés” (Medical Education) is an important part of teaching activities at the university. In 2008, the editor became Professor Béla Merkely. Thus, cardiology is a prominent theme in the journal. Extra editions appear with summaries on mandatory cardiology lectures, and these are very helpful for students and colleagues preparing for specialty board exams.

The clinic is an important training institution in cardiology specialization, because there are only three institutions with cardiac surgery background in the central Hungarian region, where the specialist doctor candidates can spend their internship year. Medical training is organized by renown professionals, such as Dr. Astrid Apor, Dr. György Bárczi, Dr. Orsolya Kiss, Dr. Ibolya Marozsán, Dr. Zsolt Szelíd and Dr. Pál Soós. It is

Professor Tivadar Tulassay, university president visits the clinic on the first “Day of Cardiology” in 2007.

Professor Béla Merkely and vice president Dr. Dávid Becker on the left

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Practical education at the clinic in 2010, dr. Endre Zima, adjunct, on the right

a hard task to correlate the practical training of 180-200 Hungarian, and about the same number of English speaking medical students, and make it effective, enjoyable and memorable as well.

New wards, new instruments, new possibilities Since invasive and instrumental cardiology care had more and more patients, the old building on Városmajor street turned its former Vascular Surgery Ward into a Singleday Cardiology Unit. The new ward made it easier to accommodate patients treated with arrhythmia or pacemaker implantation.

In coronary interventions, new procedures were established, including heart catheterization through the radial artery, which made it possible to abandon the 12-24 hour bedridden period with pressure dressing after the operation, and allowed the patient to return home on the evening of the operation day. Other new and revolutionary procedures of this era included rotablation, carotid ultrasound, and main coronary intervention.

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Professor Kálmán Hüttl, radiologist at work in 2011. Under his direction, the clinic became a stronghold of Hungarian interventional radiology

electrophysiology laboratory, directed by Dr. László Gellér, gained the continuous medical education skilled center title, making the clinic even more prestigious in postgraduate education. The laboratory includes a modern CARTO navigation system, and carries out ablation therapy for supraventricular arrhythmias, catheter ablation for atrial fibrillation, and a wide range of implantations, using cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) as well, according to professional recommendations.

In the meantime, the clinic’s diagnostic non-invasive imaging equipment expanded as well. In 2012, eight top quality echo machines serve the patients and are used for research projects. Three echocardiography rooms serve the raising number of outpatients, and host undergraduate and postgraduate courses. The use of speckle tracking echocardiography (STE) and intracardiac echocardiography (ICE), under the supervision of Dr. Astrid Apor and Dr. Elektra Bartha, was a great forward step in the scientific development of the clinic.

The radiology department, directed by Professor Kálmán Hüttl, has been using computed tomography (CT) and magnetic resonance imaging (MRI) for decades. The diagnostic unit on Határőr street received new MRI and CT machines during the last four years, and with invasive and minimally invasive cardiology coming to the forefront, these machines became great assets to the cardiology program as well.

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The new MRI equipment in 2008. Focusing on cardiovascular imaging

The 1.5 Tesla MRI scanner started its operation in 2008, on the opening day of the Semmelweis Symposium. The building’s wall had to be removed, while a huge crane installed the heavy machinery, which was already filled with several hundred liters of liquid helium to chill the inner parts.

This equipment is highly fit for cardiovascular imaging. It is used in testing the state of the heart muscles, in monitoring cardiac remodeling, and in heart muscle disease diagnosis. The results are highly useful in planning arterial interventions, or in deciding between catheter-based and surgical procedures. Close monitoring of high-risk patients is also possible, even in anesthesia.

When the new scanner was installed, the institution signed a scientific contract with the manufacturer, and became an official testing place, with a chance to influence the path of further developments. The cardiac MRI test teams include cardiologists and radiologists alike, helping one another. Professor Merkely invited Dr. Attila Tóth, radiologist specialist, who spent a year in the U.S., participating in a cardiac MRI research at the University of Alabama, to come home for the arrival of the new machinery. He was happy to do so, and along with Dr. Hajnalka Vágó, established a renown test and research base.

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The installation ceremony of the 256-slice CT machine in 2010. Professor Béla Merkely and university president Tivadar Tulassay on the picture (taken by Balázs Merész)

The 256-slice CT machine was installed in 2010. At the time, it was the most up-todate CT equipment in Central Europe.

Modern technology is of no use without specialists who can operate it, so Professor Merkely invited his former student, Dr. Pál Maurovich Horvát to return from Harvard University, and launch the cardiac CT program. By now, it has gained worldwide recognition, and holds regular training courses, called Cardiac CT Academy, with great success.

Internal renovation continued in the building, the CT and the MRI examining rooms were placed on the same floor, and outpatient care was moved to another building for the most part. The clinic serves about 80 thousand out-patients each year. The Cardiology Center needed more in-patient beds, so new patient rooms were created in another wing.

In 2009, each clinic in the Városmajor Clinical Block received the ISO qualification, and the Cardiology Center was named “Hospital of the Year” on an internet-based voting.

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Surgeon and his patient 20 years after the heart transplantation, in 2012.

Sándor Schwartz with a “new heart”, and his doctor, Professor Zoltán Szabó

New heart, new life… The heart transplantation program The culminating program of complex cardiovascular care is heart transplantation. In Városmajor, adult heart transplantations have been conducted since 1992. The first Hungarian heart transplantation was carried out by Professor Zoltán Szabó, then the clinic’s director. In 2012, a special interdisciplinary work group of cardiac surgeons, cardiologists, internal doctors, immunologists and intensive therapy doctors was organized.

The clinic’s patient load required much more space for in-patient care, and a special intensive therapy unit was opened in 2012, with ventricular assist device (VAD) support.

The first Hungarian artificial heart transplantation was conducted at our clinic in 2008.

Close cooperation between surgical and non-surgical cardiology care made it possible to start a trans-catheter aortic valve implantation program in 2011.

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The town of Budakalász: a sample of the Hungarian population The population screening test, started in 2011, and called Budakalász Epidemology Examination, is an important part of the clinic’s scientific activities. As a local Framingham study, it provides data on cardiac and vascular disease rates within a community on the border of the capital and the countryside. The examination will include regular follow up tests to reveal the presence or lack of preventive behavior and ties to the healthcare system.

Fair Play Specialists from the Cardiology Center regularly participate in the cardiology examination of top athletes, including the Hungarian Olympic Team since 2007. The Cardiology Center and the Traumatology Department of Semmelweis University became a FIFA Medical Center of Excellence in 2011.

The all-important foundation: research The clinic’s Experimental Laboratory, awarded with GLP (good laboratory practice) since 1996, is a renown Hungarian research base of in vivo animal experiments. Professor Sándor Juhász-Nagy established this laboratory back in 1966, as a young man at age 33. He raised generations of future researchers and physicians here, many of whom now hold leadership positions at prestigious universities and centers both home and abroad.

His students include the renown cardiac surgeon, Professor Lajos Papp, the talented researcher, Professor Miklós Tóth, and the devoted representative of modern cardiology training and research, Professor Béla Merkely, present director of the Heart Center. He carried on an independent interdisciplinary program since the start of doctoral studies (in 1993), which produced 39 PhD dissertations until now. Most of the research specialists at the new Cardiovascular Center were once his students.

In line with the demands of the time and international trends, Professor Béla Merkely substantially widened the scope of research programs at the experimental laboratory, but first he oversaw a through renovation of the building and renewal of the equipments (in 2009). For staff expansion, he invited Dr. Tamás Radovits, student of the renown cardiac 178 Th e

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Professor Béla Merkely cardiologist, and Professor Zoltán Nagy neurologist. Cooperation within cardiac and vascular surgery professions became the token of the clinic’s operation and development

surgeon, Dr. Gábor Balázs Szabó, who received his PhD here, and then went to work at the Heidelberg University Clinic. The highly successful, excellent young researcher brought a new zest to in vivo small animal experiments in connection with cardiovascular interventions.

The European-level, highly admired research laboratory includes a modern x-ray machine, a rare Leycom pressure-volume measuring device, and a rather new heart engine for hemodynamic and electrophysiology animal experiments. The renovated building has an in vivo and an in vitro small animal laboratory, as well as a genetics laboratory, opening up new possibilities within the clinic. At the cell and molecular biology laboratory, Dr. Judit Skopal and Dr. Gábor Földes direct diverse research projects, a high percentage of which fall back on international scientific cooperation.

16 doctoral dissertations were born within the PhD program between 2003 and 2012, under the direction of Professor Sándor Juhász-Nagy, and then Professor Béla Merkely, about half of which relate to basic cardiac and circulatory system research at the experimental laboratory.

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has gained lasting merits in the field of cerebrovascular disease and stroke treatment.

The primary research field of his colleague, Dr. Judit Skopal, who works as head of the laboratory, deals with molecular mechanisms of homeostasis in acute myocardial infarction and in acute stroke. Professor Nagy undertakes educational tasks as well, and teaches integrated professional knowledge to the young colleagues at the clinic.

Building bridges: the Semmelweis Bridge Project The Semmelweis Bridge Project, launched in 2008, was a great turning point in the scientific activities of the Cardiology Center at Városmajor. Supervised by Professor Béla Merkely, the program aimed to establish sustainable international multidisciplinary relations.

At the international press conference of Semmelweis Symposium in 2008. From left to right: Professors Hugo Katus (Heidelberg University), Béla Merkely, Heikki Ruskoaho (University of Oulu), Stefan Janssens (Catholic University of Leuven), Udo Hoffmann (Massachusetts General Hospital) and Miklós Tóth

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Live coverage from the electrophysiology laboratory in 2010. Dr László Gellért at work

The project focused on pathophysiological processes leading to heart failure and a­ thletic heart, and produced an international research group of about 250 renown specialists and young researchers, involving 34 collaborative academic partners.

The project’s opening event was the 17th Semmelweis Symposium, which was at the same time the public presentation of the Cardiology Center to the university students, with the following motto: “Building bridges from the basics to invasive cardiology”.

Lectures were held at the Semmelweis University’s Városmajor Clinical Center and at the nearby Barabas Villa Conference Center, and over five hundred participants arrived from 20 countries of the world. 29 international lecturers presented plenary talks, and there were 7 case studies presented with online coverage. In his preliminary remarks, Professor Ákos Koller commemorated Professor Sándor Juhász-Nagy, one of the greatest Hungarian research cardiologists, a mentor to almost all in attendance, who continues to be a scholastic example to us.

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Dr. Dávid Becker, vice president, giving a talk at the Semmelweis Symposium in 2008

r­esearchers in domestic and international cooperation. In addition, it motivated experienced researchers to come and work in Hungary.

The program established close ties in cardiovascular research with several institutions, including the Catholic University of Leuven, the Harvard Medical School in Boston, the Heidelberg University, as well as the Imperial College in London. Results included several joint publications and one patent, the return of seven researchers from abroad, as well as the start of 18 PhD studies. At its conclusion, it was designated an example project, and at the clinic, we were able to present its results to 50 high EU officials.

The project made it possible to renew basic research concepts and adapt international research methods to cardiovascular fields. It gave a real boost to sport cardiology in Hungary. Over 200 Olympians and top athletes were screened, with the aim of drawing an objective line between the tough heart of an athlete and an abnormal athletic heart, making it more likely to prevent the latter. A biobank of over one million biological data was organized, and a biochip was developed to detect signs of sudden heart failure, along with the parameters of physical performance borderlines.

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The results also made it possible to have longer transportation time spans in heart transplantation, and to evolve functional heart muscle cells from embryonic stem cells.

Two years later, in 2010, results of the Semmelweis Bridge Project were presented at another Semmelweis Symposium. The Semmelweis Bridge Project was supported by the European Union, and co-financed by the European Social Fund and the European Regional Development Fund.

Cardiac surgery between 2003 and 2012 Cardiac surgery during this era – with rapid developments in invasive cardiology care – started to focus on interventions with pure surgical indication. Dr. Zoltán Szabolcs, associate university professor directed the Cardiac Surgery Department during this era at the Department of Cardiovascular Surgery. 2004 marked the highest number of operations in a year (816), with the initiation of several important surgery techniques, such as beating heart or off pump coronary surgeries, ascending aorta reconstruction on Marfan syndrome patients, axillary artery cannulation on type A ascending aortic dissection patients, and modern surgical procedures on massive pulmonary embolism. The new, sub-intensive observational patient room came handy for patients past the strict postoperational state, but still in need of constant supervision.

Cardiac surgeons and cardiologists laid the cornerstone of surgical care against heart failure, the first artificial hearts were implanted, and the clinic’s 100th heart transplantation took place during this era. The first combined heart and kidney transplantation was conducted. Bloodless surgery protocols were initiated, and became routine procedures for Jehovah’s Witnesses who reject blood transfusions.

In the university’s curriculum, several courses deal with cardiology and cardiac surgery, coupled with clinical practice in Hungarian, German and English as well. Post-gradual training is also available for cardiac surgeon or cardiothoracic surgeon candidates.

Cardiac surgery research projects include surgical therapy possibilities against heart failure, left ventricular aneurysm surgery, viral causes of dilated cardiomyopathy, inotropic agents, and experimental heart transplantation on animal models.

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Vascular surgery between 2003 and 2012

Professor György Acsády

In 2003, Professor György Acsády, vascular surgeon, replaced Professor Attila Nemes in the director’s chair at the Department of Cardiovascular Surgery. Until 2007, the clinic offered cardiovascular and cardiology care, as well as invasive and non-invasive diagnostic imaging. He preserved the clinic’s liquidity even in hard economic circumstances, and directed most of its spending toward maintaining quality in its operation.

During the second period, between 2007 and 2009, as we already mentioned in connection to realignments at the university, the departments with surgery programs were separated from cardiology care and non-invasive diagnostic imaging. The medical administration of the time prescribed drastic decrease in the number of available hospital beds, and imposed an efficiency bar.

The “iron man” and the “iron woman” The Vascular Surgery Department was on duty for the capital city three days a week, and admitted patients with specific or serious complaints (such as aortic dissection, thoracic-, thoracoabdominal- or suprarenal aortic aneurysm, progressive stroke). The use of retraction systems was initiated for large abdominal surgeries during this time (we called these systems iron man and iron woman), making safe operation possible for as few as two doctors only – highly useful in emergencies. This was a tough period, with especially hard circumstances for the vascular surgeons.

When the Department of Cardiovascular Surgery was divided in March of 2009, a central surgery block was created with its own director: Dr. Péter Sotonyi. One vascular surgery room received a long-anticipated digital subtraction angiography (DSA) machine for hybrid operations and stent graft implantations. Vascular surgeon training continues in three languages (Hungarian, English and German), both for medical students and medical engineering students in partnership with the Budapest University of Technology 184 Th e

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and Economics. The clinic remained a countrywide center for vascular surgeon specialist training and specialty board exams.

6-7 doctors per year receive vascular surgeon specialty licenses here. The clinic’s nursing team was recognized for its dedication by receiving “hospital of the year” award in “nursing and attending services” category, both in 2010 and in 2011.

It is clear now, that the period starting in 2003 witnessed invasive and minimally invasive therapy coming to the forefront. Under the direction of Professor Béla Merkely, the Cardiovascular Center was a flagship in this movement, with great advancements during the first nine years, both in patient care, in education and in research. By the end of 2011, a new synthesis was needed in cardiology, cardiac surgery, vascular surgery and diagnostic imaging. The next chapter outlines this change. We could not list everyone involved, but the present doctoral staff of the clinic is listed at the end of this book.

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Professions through time The history of anesthesia and intensive therapy at Városmajor Anesthesia works in silence, unnoticed and without pain, for that is its mission. It is carried out well if it remains unseen.

The Institute of Postgraduate Surgeon Training was established in 1951, under the directorship of Professor Imre Littmann. Anesthesiology dates back to this time period as well. Professor Littmann commissioned Dr. Pál Keszler, who was originally a surgeon.

His three students, all Lászlós as their first name: Pálos, Lencz and Wittek, became key characters in Hungarian anesthesiology. Professor Keszler carried out the first Hungarian tracheal intubation in János Hospital, and designed an anesthetic machine, 50 of which were built. During this era, surgeons took turns in providing anesthesiology for one other during operations, but the need arose for an independent discipline, covering anesthesiology and invasive therapy.

The early techniques At the beginning, most cardiac surgeries were carried out with local anesthesia or ethernarcosis. Children were chilled in icy water. With the development of cardiac surgery and the disperse of median sternotomy, technical intubation and intratracheal narcosis became routine procedures.

Dr. László Pálos laid down the basics of cardiac surgery anesthesiology. In 1957, Pálos and Keszler reported on 700 cardiac surgery anesthesia in a German periodical, 98% of which were carried out in intratracheal narcosis. Keszler used double lumen tubes for lung surgeries as early as 1955. Our institution was lucky to have the profession’s pioneers work here.

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Key characters During the late 1950’s, early 60’s, Dr. Andor Kulcsár and Dr. István Harsányi worked at our clinic, followed by Dr. Katalin Szánthó, who was a leading anesthesiologist, and conducted cardiac surgery anesthesia for the most part. She completed her education in the Soviet Union.

Dr. Imre Kalmár (the “Father) was one of the most charismatic characters of Hungarian anesthesiology. He was originally a surgeon, and started to work at our institution in 1972. He directed cardiac surgery anesthesiology from 1975 until his death in 1997.

He instructed many in the tricks of the profession, several young anesthesiologists visited his surgery room.

In parallel, vascular surgery anesthesia and intensive therapy was directed by Dr. Eszter Turbók, who visited at the clinic as early as 1958 as a student, and after a short detour, worked here first as a surgeon, and then as an anesthesiologist until her death in 2005.

She was known for her short temper and golden heart.

In the early 1970’s, Dr. Margit Százados joined the team. She was much reserved and highly beloved by the patients. She worked here until her retirement. She often said: “the surgeons are already at home, drinking their second beer, when 4-5 anesthesiologists still roam the House”. She was followed by Dr. Márta Olajos, Dr. László Kónya, Dr. József Soós, Dr. Ádám Kecskés, Dr. Éva Pongó and Dr. Irén Horváth.

Members of the next generation include Dr. Gabriella Nagy (working here between 1982-99), who worked out a spine protection technique in thoracic aortic surgeries, and Dr. Erzsébet Makláry (1983 until her early death in 1984). Dr. Ágnes Petrohai conducted pre-operational care of heart transplantation patients, and along with Dr. Gyögy Nyikos, was a long-standing member of the anesthesiology and intensive therapy team. Dr. Katalin Széphelyi, Dr. Ildikó Gálfy and Dr. Mária Windisch are still active members of this generation, about whom Professor Attila Nemes said the following: “Anesthesiology and intensive therapy not only provide the necessary conditions, but also ensure that whatever the surgeon dares to do and can do, will lead to success at the end.”

Dr. Ida Matkó, arriving in 1992, was another key character of anesthesiology in Városmajor. She directed cardiac surgery anesthesiology and intensive therapy after the death of Imre Kalmár, until 2004. Young and beloved members of this team include Dr. Astrid Apor, who now works at our institution as a cardiologist, and Dr. Antal Takács. Dr. 187 Th e

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Ilona Bobek joined us from the Transplantation Clinic, and initiated continuous renal replacement therapy for kidney injury, as well as epidural anesthesia at our clinic.

Holistic perspective In 2004, Dr. János Gál, just returning from the Cardiothoracic Surgery Center in London after five years, was appointed to direct the Cardiovascular Anesthesiology and Intensive Therapy Unit, now forming one department. He brought along new and zestful specialists, such as Dr. Rita Russai, Dr. Ferenc Kővári, Dr. Tamás Varga, Dr. Kristóf Rácz and Dr. Miklós Kertai.

Several new anesthesiology techniques, already in routine use in Europe, were established and synthesized with former successful clinical practice. The old staff members and the new colleagues came to work in unity.

In 2008, the Semmelweis University’s Anesthesiology and Intensive Therapy Clinic, directed by Professor János Gál, centralized anesthesiology and intensive therapy care Professor János Gál, director of at the university. The Városmajor team joined and became the Anesthesiology and Intensive a stronghold in support of Professor Gál. Members of this Therapy Clinic generation include Dr. György Bogosi, the young talent who suddenly died since, Dr. László Szudi and Dr. Erzsébet Paulovich, now department leaders, as well as Dr. László Bucsek, Dr. Endre Német, Dr. Dorottya Kiss, Dr. Krisztina Madách, Dr. Eszter Tulassay, and Dr. Eszter Papp.

Anesthesia of the first artificial heart implantation The first artificial heart implantation in Hungary took place in 2008. Dr. János Gál and Dr. Ildikó Gálfy did the anesthesiology, with Enikő Silló-Pál and Krisztina Horváth assisting. The operation was a challenge for not only the surgeons, but for the anesthesiology and intensive therapy team as well. This experience paved the way for the first permanent 188 Th e

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artificial heart implantation in Hungary in 2012. Dr. Tamás Varga, the excellent specialist with experiences in England, was the anesthesiologist.

Dr. Ádám Soltész is an interesting character, and emblematic figure at our institution.

Once an assistant nurse, he became a cardiac technician and a medic nurse, overarching the time periods and generations mentioned above.

All in all, the anesthesiology and intensive therapy unit of Városmajor has always been a flagship and a key factor in not only cardiac surgery anesthesia and intensive therapy, but all Hungarian anesthesia and intensive therapy care. The institution and all those who were active participants in this lovely story can be proud of their accomplishments.

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Our Vision – at the Városmajor Heart Center The last decade brought great improvements in the treatment of cardiovascular disease, making it possible to cure formerly fatal cases, and lowering the death rate of serious cases (e.g. acute myocardial infarction) with modern therapy. The advancement of new sub-specialties, and the establishment of centers with dedicated, high-tech infrastructure have made these improvements possible worldwide.

15 years ago, we witnessed a growing detachment between invasive cardiology and cardiac surgery, as well as a breach between vascular surgery and interventional radiology, leading to possible competition and lack of cooperation. In this era, if a hearth catheterization laboratory was established at a unit lacking cardiac surgery, it was seen as a step forward, proving that the safety level of routine heart catheter interventions virtually dismissed the need for immediate, local cardiac surgery help. Noways, scientific development brought these together, and the highest state of the art coronary interventions are done with the help of high-tech cardiovascular imaging – spatial echocardiography, cardio-MRI and cardio-CT. Thus, we now have modern cardiology centers where the whole progressive spectrum is available.

These advancements reformed the treatment methods and the structure as well. Much of former in-patient medical care became feasible within an out-patient framework. A few years ago our method of outpatient, ambulatory pacemaker-implantation or diagnostic catheterization procedures with just a few hours of monitoring were deemed unimaginable even among professionals. Now they are fully accepted, and can save a lot of money by eliminating the cost of unnecessary in-patient care. Even when in-patient care is necessary, it tends to occur in a shorter time-span, even in the case of a serious illness, such as a heart attack. It is now a typical scene that a patient with myocardial infraction is brought in by the ambulance, the blocked coronary artery is opened up within a few minutes; the complaint being resolved, the patient starts smiling and feels well. The doc193 Th e

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tor then turns to the distressed relatives outside the door, setting them at ease. The patient can leave the clinic, cured in three days –with the assurance of proper rehabilitation.

At the same time, the ratio and relative length of intensive care had to be raised in several areas, such as in the highest level (requiring respiration, invasive hemodynamic monitoring, kidney-replacement therapy, circulation-support, artificial heart treatment), top-intensive departments, as well as in the profession-specific intensive, and the intermediary intensive care departments, where there is closer monitoring, observation and guarding. Apart from standardized pharmacological treatment therapies based on a wide range of evidence, cardiovascular care tends to move towards semi-invasive and invasive therapies, uniting formerly independent disciplines (such as cardiovascular imaging, cardiology, cardiac surgery, vascular surgery, and intensive therapy). In consequence, serious cardiovascular disease can be cured more effectively, resulting in substantial life-span expectancy raise.

Catheter-based intervention to myocardial infarction is an outstanding example of the above. This method lowered the hospital death rate of this potentially fatal illness to 3-4%, and there is substantial improvement in long-term outcomes as well. In the last decade, the life expectancy at birth went up with 5 years, for the most part due to

View of the Cardiovascular Center

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The medical staff of “Városmajor” in 2012, joining Cardiology, Cardiovascular Surgery, and Anesthesiology

widespread access to cardiovascular care, more specifically interventional cardiology in Hungary.

The prestigious “Városmajor” – formerly called the Department of Cardiovascular Surgery – provides a unique structure, fit to provide multidisciplinary cardiovascular care both now and in the future. Also, policy directives and decisions made it clear that the institution would become the chief institution of critical care in the Buda region, and would continue to become a countrywide center for certain special pathographies (for example, non-pharmacological treatment of arrhythmia and serious coronary disease, heart failure-heart transplantation, and as the Countrywide Aortopulmonary Catastrophe Center). The center thus established is a unique and indispensable diagnostic and therapeutic unit on the palette of domestic medical care. Among other things, it provides special, cardiovascular imaging (cardio-CT and cardio-MRI) services to other heart centers that are not university clinics.

In response to these challenges and contextual changes, a new organizational structure emerged by the summer of 2012, with some degree of centralization in professional strategy direction, economy and human resource policy. Of course, “Városmajor” is not professionally isolated, but enthusiastically cooperates with surrounding cardiology subcenters (Szent Imre, Szent János, Szent Margit Hospitals, Medical Clinics), and takes an active role in cardiovascular rehabilitation.

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Structural transition On July 1st, 2012, the Semmelweis University Heart Center was established as a new structural unit with a unified vision, based on uniform professional principles to provide multidisciplinary care (including cardiology, cardiovascular diagnostic imaging, vascular surgery, cardiac surgery, and profession-specific intensive therapy.). This form of structure ensures the fulfillment of objectives described above. The Heart Center provides an operational frame for three university departments (vascular surgery, cardiac surgery and cardiology) and two department groups (vascular neurology, cardiothoracic surgery).

Large-scale infrastructural development plans back up this monumental design. The first step was a full refurbishment of the 15-bed intensive unit of the Surgery Department, and the establishment of the new, profession-specific intensive care unit for heart failure-artificial heart-heart transplantation patients. Renovation work of the surgery departments on the first and second floors of the Városmajor street 68 building has began. Another grand-scale plan which aims to provide high quality care, is the installation of staff service areas (doctor’s offices, changing rooms, administrative areas) in the

The corridor of Ventricular Assist Device Intensive Therapy Department (VADITO) built for patients with severe heart failure and patients of artificial heart treatment and/or transplantation

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(1000‑1,200 m 2 large) attic of that building, because lack of space is still a major problem. If these functions, now scattered in various buildings, can be brought to this new place, the space they now occupy can be used either for patient care (turning them into modern patient rooms and outpatient examination rooms) or for education (as additional education rooms) by low-cost, but high-quality improvement plans. In addition, we plan to connect the two main buildings (at Városmajor and Gaál József Street, and at Határőr Street) either by a tunnel or by an elevated walkway.

With an eye on the university’s classic triad (patient care, education, research), we now proceed to outline the vision of cardiovascular care in general and the Heart Center in specific.

Patient care Medical attendance of acute myocardial infarction The Cardiovascular Center, and then the Cardiology Center, assumed a central role in planning and launching the regional myocardial infarction emergency attendance system in Hungary. We are the only one in the region to provide 24-hour emergency care twice a week, and take in all patients in critical condition (in shock or revitalized). Consequently, the Cardiology Center attends to the highest number of acute myocardial infarction in the country. Then there are thousands of diagnostic and invasive catheterizations, most of them in a one-day care. Since this is a countrywide center, there are special interventions as well, requiring high qualifications and centralized care (e.g. special percutaneous intervention, rotablation of highly petrified arteries, or ultrasound examination within arteries). Our goal is to provide fast and extensive care for patients suffering from artery malfunctions.

The care is efficient and fast enough that the actual hospital stay of patients who suffered myocardial infarction is brought down to just a couple of days in most cases. At the same time, permanent care and rehabilitation is indispensable for them, either as in- or out-patients, depending on their condition. This is not yet fully resolved, but close cooperation is established with the rehabilitation institutions, which is a major forward step in this area.

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Formal opening of the Ventricular Assist Device Intensive Therapy Department (VADITO) in 2012. From left to right: Dr. Miklós Szócska under-secretary, Professor Béla Merkely, and Professor Tivadar Tulassay rector

Medical attendance of chronic heart failure A renewal of the heart failure-heart transplantation program continues with significant investments: with the creation of a new, profession-specific intensive care unit for heart failure-artificial heart-heart transplantation patients, with the formation of a team of doctors and nurses with special qualifications, and with close international cooperation.

In 2012, even a few months brought tangible results: record number of successful heart transplantations, as well as the implantation and use of special ventricular assist devices.

Since joining Eurotransplant (January 1st, 2012), six patients in most critical conditions received a heart within just a few days, free of waiting list constraints.

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Successful permanent artificial heart implantation – the first in Hungary In 2012, twenty years after the first heart transplantation, the first permanent artificial heart implantation took place at the Városmajor Clinic. It was the first intervention of this kind in Hungary. The 51 year old man was suffering from serious heart failure, and had been on the heart transplantation waiting list for months. There was a constant decline in his condition, so his doctors decided on implanting an artificial heart.

The artificial heart implantation can support blood circulation to the main artery from the left heart-chamber, thus supporting the heavily impaired heartbeat. The pump itself weighs about 1.3 pounds, and it is under 10 centimeters. Since the device provides perpetual circulation, the patient with artificial heart does not have a pulse. The device works with electricity, connecting to the storage batteries with a thin wire through the

Professor Bela Merkely, at the press conference on the first permanent artificial heart implantation, in October of 2012 (photo by Balázs D. Kiss)

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skin. The batteries can be placed on a belt, so the patient is not bedridden, but can go about his or her everyday activities.

The procedure is of great importance, because implantable ventricular assist devices can raise the chances of end-stage heart failure patients for subsequent heart transplantation. In some cases, it can also serve as a permanent therapy, as an alternative of heart transplantation.

We hope that in the not so distant future, a major focus will be the implantation of full-capacity ventricular assist devices in great numbers.

Artificial heart implanted above the diaphragm, and a previously implanted pacemaker in the left shoulder girdle

The treatment of arrhythmias We see constant progress in the area of catheter-ablation techniques developed for the treatment of arrhythmia, in the area of successful, permanent treatment of the most serious arrhythmias, and in the area of combining imaging procedures (CT, MR) with device-based treatments (pacemaker, implantable cardioverter defibrillators).

Since both electrophysiological inspection (catheter-based inspection of arrhythmias) and the use of catheter-ablation techniques are making their way into everyday therapy, we plan to enlarge our institution’s electrophysiological capacity. Pacemakers for arrhythmias undergo rapid improvements; we’ll soon see electrodeless devices. At the same time, patients living with pacemakers at home can be monitored from great distances through various communication applications (e.g. mobile phones).

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Cardiovascular imaging Our institution provides full range diagnostic possibilities either for high-level, specialized, or for conservative, minimally invasive surgery care, both in an emergency, or on demand. Potentially fatal cardiovascular disease manifestations can be ideally treated in this setting.

Cardiovascular CT and MRI tests are carried out jointly by cardiologists and radiologists. The cardiologist view brings exactness into the diagnosis, and helps to determine subsequent patient treatments. Having patient care and complex diagnostic imaging in one institution not only improves the diagnosis, but has benefits in the field of education and research as well.

Computed tomography (CT) Attaining the title of a research university made it possible for us to establish an international-level cardiovascular imaging laboratory at the Cardiology Center of Semmelweis University, and purchase a next generation, 256-slice CT. Our Center is the only cardiology institution in Hungary with a modern CT instrument, making it possible to fully integrate radiology procedures into clinical care.

The non-invasive coronary angiography conducted with the 256-slice CT can often replace catheter-based intervention. In our institution, we cure CT-diagnosed, advanced coronary artery stenosis with image-guided percutaneous intervention, based on 3D CT images. It is safe and reduces costs. Mapping the artery with CT will relieve the catheter labs from a great number of negative tests. Anticipating that catheter labs in the future will primarily receive patients for intervention, it is essential to provide and develop highresolution, non-invasive diagnostic background.

The differential diagnosis of acute chest pain often poses a challenge to the clinical attendant. The symptomatology of acute coronary syndrome resembles the symptoms of pulmonary embolism and aortic dissection, so rapid and reliable diagnosis is a must. In our institution, the number of triple-rule-out (TRO) tests done by the 256-slice CT is on the rise for acute chest pain (and negative EKG). With this test protocol, chest catastrophe can be verified or ruled out within a few seconds, and the patient can receive swift and adequate care.

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while the traditional, catheter-based examination would be a more time-consuming and higher risk intervention. Heart-transplant patients’ regular invasive coronary angiography exams can also be done by cardio-CT. It is safer, and costs less than the regular catheterbased examination.

The future will underline the importance of non-invasive cardiac-diagnostic procedures both in acute, and in scheduled cardiology care. Having a catheter lab and a 256-slice CT in close proximity provides the Cardiology Center with a unique and modern imaging background, both in artery malfunction diagnosis, in the follow-up of heart-transplant patients, in planning interventions, and in acute care. This can reduce the cost of checkups, but might necessitate staff relocation on demand.

Magnetic Resonance Imaging (MRI) Countrywide, our institution leads the number of cardio-MRI examinations; the number of these will increase as the indication scope gets wider. It is very likely that MRI will take on a more important role in the exact diagnosis of heart failure, and in the assessment of the cardiac manifestation of certain systemic diseases.

Due to technical innovations and the development of surgery techniques, more and more children with congenital disorders live to adulthood, bringing with them an increased need for cardiovascular imaging technologies. The non-contrast-enhanced 3D MRI angiography method plays an important role here. Cardio-MRI will continue to come to the forefront in cardiovascular risk stratification.

Our institution is a leading center in the MRI-examination of the peripheral vascular system as well, which serves well as a base for diagnosis in vascular surgery, and in some interventional radiology interventions. MRI is important in cerebrovascular diagnostic imaging, including the diagnosis of acute stroke care. The device can meet present and future demands for complex chest and abdomen MR diagnosis. MRI checks can replace cardiac ultrasound diagnosis in more complex cases. Even though the procedure is more expensive, it is more specific and more sensitive, and thus it can become the standard examination device in the future.

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Cardiac surgery By using its full capabilities, the Heart Center, can secure a leading position for its cardiac surgery profile in the domestic field. This can come to pass in partnership with the local Anesthesia Department and the Intensive Therapy Clinic.

The primary responsibility of the cardiac surgery profile is the high-standard, professional servicing of its medical region, providing (adult) cardiac surgery care. There is room for improvement here, as stronger interactive relations are needed with cardiologists and family doctors in the region. Effective and smooth interactive relations require the organization of regular professional and scientific meetings, symposiums, trainings, and quality assurance controls.

Cardiac surgery interventions In relation to the cardiology team, a bilateral partnership with the Cardiology Department, is essential in cardiac surgery. The two departments are in professional consultation regarding patient care on a daily level, so we organized a Heart Team with cardiologists and cardiac surgeons for successful correlation. We plan to conduct more mitral valve repair surgeries (even for mitral vitium complaint-free patients), and minimize their invasivity with minithoracotomy and thoracoscopic surgery.

We would like to make surgical ablation a routine procedure for patients in cardiac valve or coronary disease surgery, who are experiencing chronic atrial fibrillation.

On the other hand, close cooperation is needed between the cardiac surgery and the vascular surgery team as well. This cooperation can yield complex care for cardiovascular disease requiring surgery (for example, in the case of coronary disease and supra aortic arteries).

These are attainable goals, based on reality. Of course, domestic and foreign training of professionals is a must. It is important to keep in touch and correlate with centers at home and abroad. The cardiac surgery team has to be placed in an international contact net, where the cardiac surgery centers of neighboring lands play a vital role.

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Vascular surgery Vascular surgery in Hungary emerged and consolidated at the Városmajor Clinic from the early 1950’s. Our leadership role is constant in this field: we not only have the highest numbers, but offer the full range of surgery procedures, including interventions. Our primary objective is to keep this role and develop it even further, with a primary focus on quality.

Our clinic is the only one in Hungary with a cryopreserved biobank of vein grafts from multiorgan donors, often providing the last chance of saving a limb for septic patients unable to receive artificial veins.

The care of patients with peripheral vascular disease often requires the combined experience of an angiologist, a radiologist and a vascular surgeon. For optimum patient care, we plan to establish disease-specific outpatient clinics (for example, vascular malformations [fistulas, tumors], congenital vascular malformations). Since such conditions are rare, recommended methods of care have not yet been determined in Hungary.

In line with international trends, which favor less invasive interventions, we plan to enlarge the range of outpatient, one-day, and short hospital stay treatment methods (e.g. percutaneous arterial interventions, endovenous surgery).

Vascular surgery interventions Stent graft implantation is of major importance in aorta surgery, it is only due to lack of funding that we do not apply them more. There is a great demand, though, because stent graft implantation is less straining, and would be suitable for 60-70% of the 150 patients undergoing open aneurysm surgery each year. Our aim is to raise the proportion of stent graft usage and open aorta surgery.

Another field for improvement, requiring the cooperation of all professions at Varosmajor, is raising the regularity of hybrid surgery. If there is no need for surgical stitching on the cardiovascular anastomosis, it is less stressful for the patient, and saves costs for the medical budget (less blood, shorter hospital stay both in the intensive care and in the regular unit, etc.). The hybrid operating theatre could regularly carry catheter-based valve operations and stent graft implantations, raising the success rate of operations.

The use of catheter-based thrombus aspiration devices is under consideration, for opening newly closed grafts, or treating fresh cases of large deep vein thrombosis. We have 204 Th e

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witnessed stagnation in the treatment of the latter, so this can be a breakthrough method, freeing both the patient and society from the annoyance of treating post-thrombotic syndrome for decades at end.

The Semmelweis Plan allocates an outstanding, countrywide acute care role to the Heart Center in the treatment of vascular catastrophes, it will serve as a Countrywide Vascular Catastrophe Center.

Multidisciplinary plans in patient care Heart transplantation (HTX) program revised During the last 20 years, Városmajor has risen to the mid-level of international centers conducting heart transplantation, in terms of numbers. In order to reach the amount and quality required by Eurotransplant, however, we need to rethink the whole HTX program. It should be based on the goal-oriented, professional cooperation of cardiology and cardiac surgery professionals. Together, they should create a constant supply of patients for the waiting list. At present, the low number of patients on this list is the greatest hindrance to the efficiency of the adult heart transplantation program.

The last few years witnessed major changes in heart transplantation practices worldwide. The number of chronic heart failure patients waiting for heart transplantation went down, while the number of acute heart transplantations went way up. The reasons are manifold. First, the development of pharmacological and non-pharmacological treatment for chronic heart failure greatly increased the quality of life and life expectancy of these patients. Second, due to modern, widely available catheter-based myocardial infarction treatments, more patients survive the first phase of myocardial infarction. Without this treatment, the first phase often results in severe myocardial impairment, which is lifethreatening in the long run. The third reason is the early recognition of serious acute heart disease types (fulminant myocarditis, pregnancy-related heart failure) that are fatal without heart transplantation, and affect the younger generation for the most part.

The composition of patients waiting for acute heart transplantation has changed: threefourth of them are suffering from coronary-based disease. According to international 205 Th e

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data, 50% of heart transplantation patients are in the most serious, UNOS 1A classification, another 35% are in UNOS 1B classification, requiring constant intensive care, and only 15% falls into less serious categories. The pre-operative care of these acute patients greatly varies from the care of chronic heart failure patients. They require special intensive therapy, along with ventricular assist devices (IABP, ECMO, artificial heart). Successful development and the completion of this project is a major responsibility of cardiology in the near future.

Városmajor Clinic has served as the center of adult heart transplantation for the last 20 years, so right from the beginning. We measure up to this responsibility. In Hungary, there are 13-22 adult heart transplantations each year, which is reasonable for a transplantation center, even by international standard. The Heart Center plans to continue with this amount now and in the near future.

By joining operative and non-operative professions, our institution offers modern diagnostic and therapy technologies, all in one, and all through the transplantation process.

Operating block, inner corridor in 2012

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The first TAVI implantation at the clinic in 2011. Professor Béla Merkely on the left with his back to the camera

Preparation for the transplantation takes place at the newly established heart failure ambulance. New heart patient care is another complex task, we plan to organize it in the near future. These patients often see their doctor for other than cardiovascular problems, and because of their permanent immansupprimal state, the transplantation center is the best place to treat them.

Hungary joined Eurotransplant in 2012. From a technical point of view, our Insti­ tution is fully capable. Our specialists have been conducting heart transplantations with internationally-recognized methods for two decades. We are putting a special emphasis on successor training to secure the future: young doctors who start from their “alma mater”, gain experience in foreign centers as well, and follow advanced therapeutic principles. The Heart Center will continue to raise professionals well immersed in heart transplantation.

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Catheter-based valve interventions Catheter-based aortic valve implantation, in the joint field of cardiac surgery and vascular surgery, has already started at our clinic. We have conducted 11 interventions. While anticipating lower expenses in connection with the device, and the enlargement of the professional circle, we look forward to much more interventions of this kind. In addition, we shall proceed with catheter-based corrections on mitral valve regurgitation.

Joining the transcatheter aortic valve implantation program (TAV I), as an extension of the program, we shall start on transapical artificial aortic valve implantation (conducted with a minimal surgical incision on the chest wall).

Hybrid operative solutions The seasons of outstanding development in the history of the Városmajor Clinic have always been characterized by overarching visions. The successful decisions, ones that maintained international standards at the clinic, had an interdisciplinary perspective. These included the launching of the heart transplantation program, the establishment of CVC, the development of the stent graft program, the renovation of the intensive therapy unit, and the creation of VADITO (Ventricular Assist Device Intensive Therapy Department).

A good complement to all these is the hybrid operating theatre project, which integrates the operational activities of several disciplines. Apart from traditional open surgery procedures, methods integrating multiple disciplines, thus lowering the degree of invasivity, are also put to practice. We plan to turn two former small operational rooms into one larger room, serving operations on the borderline of cardiac surgery, vascular surgery, interventional cardiology and radiology. This operating theatre would be equipped with state-of-the-art DSA, operational and surgical technology, so that TAV I, aortic stent graft implantation, open coronary revascularization-PCI, peripheral hybrid vein surgeries, and transapical valve implantations could take place. If we connect the new operating theatre with skilled lab units – such as an endovascular simulator – or provide direct audio-video connection, various graduate, postgraduate or international trainings can be held. This development would consolidate our leadership role in the cardiovascular field.

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Establishing a marfan syndrome center Marfan syndrome patients, with skeletal system and cardiovascular complications, often require complex, multidisciplinary cardiac surgery, vascular surgery and cardiology solutions. The Heart Center coordinates the Hungarian Marfan Fund, operating at the Clinic’s Városmajor Building, and thus provides for the countrywide care of cardiovascular complications of marfan syndrome patients. Young colleges can join research projects on the marfan syndrome’s genetic background, and learn more about research methods in particular and the approach in general.

Countrywide aortic center Our goal is to establish an aorta surgery team providing countrywide care. A Countrywide Aortic Center, an interdisciplinary task-force, could provide an appropriate professional frame for the successful treatment of several types of vascular disease, from the aortic root to the aortic bifurcation. The complex treatment of aortic aneurysm and dissection (both acute and chronic) requires tight interconnection between vascular surgery,

Patient room at the Ventricular Assist Device Intensive Therapy Department (VADITO)

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cardiac surgery, and endograft (interventional radiology) techniques. This program can be carried out by an aorta team: a vascular surgeon, a cardiac surgeon, and an interventional radiologist working in cooperation.

Bloodless cardiovascular surgery center We plan to establish a Hungarian Bloodless Cardiovascular center, with close cooperation between the surgical team, the anesthesia and intensive therapy teams, the laboratory, and the research laboratory. The center’s main responsibility would be the bloodless servicing of primarily elective surgical interventions. It is becoming increasingly common for the patient to request the avoidance of blood transfusion. In response, we plan to establish departments with proper professional and technical equipment and staff.

Education The departments and educational groups of the Heart Center offer graduate medical training in three languages (Hungarian, English and German). The unified educational syllabus is geared toward patient-centered training in small groups, both in the curriculum of theoretical and operative professions.

Recently, a system fit for the 21century, was established which provides live online connection between the operational rooms of the Heart Center and the lecture hall.

This provides a chance for all our students to look into surgical work. The Cardiology Department has organized an annual Day of Cardiology since 2007, when each student can practice the use of diagnostic devices, resuscitation, and special ECG information.

On this day, the university offers a unique interactive system, where participants can test their knowledge. The Day of Cardiology has become a well known event at the university, and we want to keep and enrich its professional content in the future. The last few years brought a growing proportion of foreign students, and we aim to provide high-standard education in each cardiovascular medicine program.

Our institution offers postgraduate specialist training, as well as continuing medical education. Preparation programs for basic and upper degree exams are also available. The Heart Center’s staff carry out third-level care on several disease types, making the clinic an ideal place for special professional training. Apart from keeping these functions, we 210 Th e

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plan to teach all professional innovation we launch, after proper practice. We also plan to introduce vascular surgery and cardiac surgery as one subject: cardiovascular surgery, taught for one semester in graduate training, at least as an elective course.

In addition to basic educational functions, the institutional staff provides various special practical trainings in small and large groups. These include special courses for medical students, and courses teaching specific surgical procedures. Our institution’s foreign partners have also sent annual requests for us to hold specific courses in their educational agenda. Education offers our institution a chance to solidify our reputation, and we plan to start interdisciplinary training in post-graduate medical education.

Participation in the PhD program of the Doctoral School provides the background for research conducted in our units at the Heart Center. Apart from numerous defended PhD dissertations, we have about ten new PhD students each year, with research grants.

In addition, our supervisors offer regular PhD courses and symposiums. After the fusion, we will be able to offer new, multidisciplinary PhD courses, with leading researchers and specialists provided by our institution.

Research Our institution has been leading center of Hungarian experimental surgery for decades. Building on previous major experimental results, and particularly since the launch of CVC and the 2003 Cardiology Center, research activity on clinical cardiology has expanded as well. The Heart Center offers a wide range of experimental and clinical research. In vitro and in vivo experimental work is being carried out at the research laboratory, renovated in 2009. An operating section for operative interventions on small and large animals was put into place, along with an adjacent animal house. Devices and measuring instruments at the operational room are fit for electrophysiological and catheter-based interventions, as well as conducting smaller and larger scale surgeries (even experimental heart transplantation).

In addition to basic experimental research, we conduct basic clinical research, the results of which are used in everyday clinical practice. The research laboratory and the clinical laboratory serve the needs of potential, systematic research projects, from molecular to full body level. The near future will provide for a wider range of such projects, focusing on multidisciplinarity.

We have been in close contact with various foreign universities (University of Hei211 Th e

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delberg, Germany; catholic University of Leuven, Belgium; Imperial College, England; Harvard University, USA) for years, leading to researcher’s exchange and joint scientific projects. The liveliness of these relationships becomes manifest in regular scientific programs (such as Semmelweis Symposium 2008, 2010, 2011, 2012; joint PhD courses).

Our goal is to increase the regularity of occasions when joint projects can be presented and research colleagues can report on their work.

Research funding comes from international and EU tenders. Research projects conducted at our institution have won several million Euro’s worth of grants (TÁMOP, OTK A, ENIAC). Even though the amount of grants change from time to time, we plan to be able to fund all our research from tenders. With the establishment of the Heart Center, we plan to solidify the support structure.

In addition to classic cardiovascular research, our institution launched Central Europe’s largest primer prevention survey, the Budakalász Epidemiology Study. The goal is a full cardiovascular survey on the adult citizens of Budakalász, a town in the central region of Hungary, with prospective follow-up, and the analysis of cardiovascular morbidity and mortality in social, economic and cultural context. Surveys of this kind can help determine what needs to be done in public health services, both in terms of lifestyle-change initiatives, and the organization of how needed medical interventions will be carried out.

The epidemiological survey is prospective, it will last for years, or even decades. The first results are already in publication.

The Városmajor Biobank has been established as part of the Semmelweis University’s Biobank Network. The biobank meets high-level security standards, and can handle a database of biology samples with individual identification, as well as clinical data collected from patients. The sample stock continues to grow, so we’ll need further expansion in the near future. More samples provide more opportunities for medical data collection, and can answer emerging questions. Our goal is to carry the university’s largest number of samples, and become an exemplary biobank in its operation.

The publication activity of our institution is on the rise each year. Several SSA awards, defended PhD dissertations, as well as international recognitions attest to the quality of our scientific work. Our goal is to enlarge our publication activity as opportunities arise.

Finally, if you undertook to read through the “100 years” of Városmajor, we hope you have the impression that the renewed Városmajor, the Semmelweis University Heart Center, standing on the firm foundation of its distinguished past, takes a bold forward step into the future by establishing a university cardiovascular center, serving the recovery of future patients with ever-higher efficiency.

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The centennial year: 2012

“Do not try to shortcut your path, but go along and make the ground more steady, the scenery more beautiful by each act of yours” - says Paulo Coelho. This is so very true for the Semmelweis University Heart Center. During the first 100 years of its operation, it did not try to shortcut the imaginary path of institutional and scientific development, and tried a great number of things along this long-drawn path. As a private sanatorium, a convalescent hospital in 1912, obstetrics and gynecology were the main sections. Soon, however the country’s first electrocardiography equipment was put to use here, and the institution became one of the most important heart centers in Hungary. The trodden path is not a low-class metaphor here, but provides steady ground for the institution.

If we look at the clinic’s centennial year through this lens, it becomes clear that the three disciplines in operation within its walls: cardiology, cardiac surgery and vascular surgery, came to form a whole by this sweaty, often hard, but respect-demanding past.

The centennial year, under the leadership of Professor Bela Merkely, is a grand image of the clinic’s tradition, as it aims to successfully implement proven clinical protocols under heavy patient loads, and to initiate and widely disseminate methods that are new in Hungary. After all, this is the role of a clinic, it has to be professional in implementing efficient patient care, making it available to all if possible, and search for new methods to reach yet higher levels of efficiency.

Presently, the clinic is the largest percutaneous intervention center treating acute myocardial infarction in Hungary. In 2012, over 6000 heart catheterization tests took place in the institution’s hemodynamic laboratory, 2744 of which resulted in percutaneous coronary artery intervention. Case seriousness is signified by the fact that two-third of the patients had acute (with or without ST elevation) myocardial infractions.

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Coronary Intervention at the Semmelweis University Heart and Vascular Center OCT: optical coherence tomography. FFR: fractional flow reserve. IVUS: intravascular ultrasound SCAD: stable coronary artery disease. NSTE-ACS: acute coronary artery syndrome without ST elevation.

STEMI: ST elevation myocardial infarction. DES: Drug eluting stent.

of cardiology care is the catheter ablation treatment of arrhythmia, aiming at their successful termination. Our clinic serves an outstanding quantity of patients in this regard too. In 2012, there were 782 catheter ablations, most of which were preceded with CARTO electroanatomic mapping.

It is important to underline that we conducted 165 atrial fibrillation ablations, and 86 ventricular arrhythmia ablations in this group. These interventions are the crown of electrophysiology, since they heal life-threatening cases of arrhythmia, or cases that are difficult to treat. Out of 321 interventions not requiring electroanatomic mapping, we treated 167 AV nodal reentry tachycardia (AVNRT), 86 atrial flutters and Wolf-Parkinson-White syndromes. We conducted 13 cryoablations at our clinic in 2012, which is rather rare in Hungary, due to its cost. 1599 pacemakers and implanted cardioverter defibrillators (ICD) were implanted to treat potentially life-threatening arrhythmia, 1269 were pacemakers, 330 were ICDs in this centennial year.

Catheterization became more and more prevalent in peripheral vascular surgery, and often present a feasible alternative to traditional surgery methods. We conducted 870 216 Th e

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Number of catheter ablations Heart and Vascular Center, Semmelweis University Budapest 2007-2012

Number of Pacemaker, ICD and CRT implantations in Hungarian Centers Semmelweis University Heart and Vascular Center

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Number of ICD (without CRT-D) implantations in Hungarian Centers in 2012 Semmelweis University Heart and Vascular Center

catheter-assisted percutaneous peripheral artery interventions at our clinic, 330 of which were lower limb artery interventions, 219 were lesser pelvis vein interventions, and 228 were cervical artery interventions.

There were 23 renal artery interventions, used in the treatment of treatment-resistant hypertension, and 16 innominate artery interventions in 2012. We expanded on the instrumental treatment potential of treatment-resistant high blood pressure in 2012, and conducted new interventions (ablation treatment of the renal artery, and implantable carotid sinus stimulator), unique in Hungary, in the following year. Percutaneous interventions came to include not only classic coronary artery interventions and peripheral vein-interventions, but are also becoming more and more a suitable alternative in valvular surgery. Our clinic was the first in Hungary to introduce transcatheter aortic heart valve implantation (TAVI) to treat aortic stenosis, and conducted 14 such interventions in 2012, for high-risk heart surgery patients.

Drug treatment-resistant heart failure patients can now be offered more and more effective instrumental treatment methods. It is important to underline that as far as we now know, the most effective method for end stage heart failure is heart transplantation in a long run, the transplantation from a brain dead person (donor) to the patient with 218 Th e

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Percutaneous intervention in the internal carotid artery, with stent implantation Semmelweis University Heart and Vascular Center

severe heart failure (recipient). However, since heart transplantation has several limitations, and instrumental treatments became more and more prevalent in the last few years.

Our clinic has been conducting cardiac resynchronization therapy, (CRT) for several years, in Hungary’s largest case-numbers, the implantation of a special peacemaker or ICD, improving heart pump function and reducing severe clinical symptoms in heart failure patients with special signal conduction disorders (left Tawara-branch block, left bundle branch block, LBBB).

At the clinic, this centennial year started the artificial heart program within the scope of using ventricular assist devices (VAD) for acute heart failure syndromes, which program got into full swing in the following years. Up to date, 26 artificial hearts were implanted at the Semmelweis University Heart Center, 10 of which were left ventricular (LVAD), 7 were right ventricular (RVAD) artificial hearts, and the remaining 9 were devices supporting both ventricular (BiVAD).

Present indications reveal three basic roles of VAD: 1. supporting end stage cardiac patients until heart transplantation – bridge therapy; 2. supporting the healing of severe but reversible, myocardial-based heart failure – bridge to recovery; 3. lifelong support 219 Th e

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for specific patients – destination therapy. Today, a heart transplantation center cannot exist without a modern ventricular assist device program. Due to primary graft failure in some patients following the transplantation, extra corporeal membrane oxygenation (ECMO) was used, and/or ventricular assist devices (VAD) were implanted, but there has been pre-transplantation cardiac support of patients until heart transplantation (bridgeto-transplant), and post-surgery cardiac support against heart failure (bridge-to-recovery) as well. Close cooperation between colleagues working in various fields is very important in this work, from fast and accurate implantation indications to the surgical implant and post-surgery intensive therapy. There has been 42 ECMO devices implanted at the clinic to this day.

The cardiac surgery section of the clinic was led by Zoltán Szabolcs in 2012, and he has been true to the forefathers’ tradition in its coordination. In 2012, the ratio of acute cardiac surgeries grew among cardiac surgeries in general, this might be a result of closer cooperation with cardiologists. In consequence, the number of open heart surgeries also grew during the last few years, and reached 733 in 2012, even though percutaneous cardiac surgery techniques rolled back that number to start with.

In order to keep up with past excellence with a heavier acute patient load, it became essential to more widely employ modern cardiac surgery techniques. The cardiac surgery department includes several high quality surgical activities. The most important programs include aortic surgery (aortic root, aortic arch, acute and chronic aortic dissection), adult heart transplantation, and the artificial heart and ECMO program getting a head start in 2012. Special activities of the cardiac surgery section also include MR-guided projection of left ventricular aneurysm reconstruction surgeries, and the so-called “bloodless” cardiac surgery service, making it possible for patients denying blood transfusion to receive accurate cardiac surgery care.

The following benchmark activities characterize our cardiac surgery activities in 2012: I: Off-pump technique in the surgical repertoire of our cardiac surgery section II: Mitral valve repair III: MR-guided projection of left ventricular aneurysm reconstruction surgeries IV: Aortic root surgery, with special emphasis on treating Marfan’s syndrome V: Adult heart transplantation (HTX) quantity and quality index VI: 2012 start of the VAD and ECMO program and first results

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Number of cardiac surgeries at the Heart and Vascular Center Semmelweis University in the last 20 years

Off-pump coronary artery bypass (OPCAB) became a major keystone of modern coronary surgery. This technique does not need a heart engine, hypothermia, aortic cross-clamping, or cardioplegia. In consequence, the patient enjoys several benefits in this technique: lower blood loss than in heart engine surgeries, lower need for transfusion, declining pulmonary and neurology complication ratio, shorter intensive care need, substantial cost reduction.

Our clinic has always put a strong emphasis on the initiation and use of this technique.

In 2012, a great number of our coronary surgeries were carried out off-pump, and our doctors in post-gradual training receive great emphasis on learning off-pump surgical techniques. In 2012, two-third of our coronary surgeries were off-pump.

Nowadays, we cannot imagine modern mitral valve surgery without mitral valve repair.

Our clinic offers the full range of mitral valve repair, from complex mitral valve repair to various ring annuloplasty types and chordae tendineae replacements. In 2012, 65% of our mitral valve surgeries were valve repair procedures.

10-20% of infarction patients develop ventricular aneurysm, most of which are in the anteroseptal-apical wall of the left ventricle. The mechanical result of a distorted ventricular structure is declined muscle contraction, prolonged diastolic relaxation time. The 221 Th e

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Intraoperative picture of an off-pump coronary bypass surgery with intracoronary shunt, on a patient with decreased left ventricular function (30% EF)

cardiac output declines progressively, which can lead to cardiac decompensation in the long run. Inasmuch as papillary muscles are involved, mitral insufficiency can arise. The mortality rate of left ventricular aneurysm without surgical correction is between 75 and 90%, according to various sources. The more distorted the ventricular is after surgery, the worse mortality ratio patients can expect without surgical intervention. The technique developed at our clinic offers a safe surgical solution for this high-risk patient group. Their short term and long term survival is closely connected with left ventricular geometry.

The first complete aortic root reconstruction took place at our clinic in 1982, and the surgical treatment of clinical cases having to do with the aortic root, the ascending aorta and the aortic arch (aneurysm, dissection), became part of our clinic’s main activities. During the last three decades (1983-2012), we conducted 328 full aortic root reconstructions, in most cases according to Bentall and Cabrol. In 2002, the Hungarian Marfan Foundation (www.marfan.hu) was established at our clinic to gather, register, 222 Th e

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Before surgery

After surgery 3D echo images before and after a mitral valve repair surgery.

Triangular resection of the anterior leaflet (A2), quadrangular resection of the posterior leaflet (P2), 1-1 neo– chordae implants (Gore-Tex® chord) in the anterior and posterior leaflets, and mitral ring implantation took place.

The patient was released to rehabilitation on postoperative day 8, following a smooth post­operative period.

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Proportion of mitral valve surgery types in 2012 at the clinic Image section 1A On the three-dimensional model, we designate the resection points (the borderline area of the intact and the decayed part of the myocardium) with reference to the cardiac apex, based on wall thickness variations during the atrial systole, or based on MRI viability assessment. The designated resection points on the anteroposterior picture are the following: A = anterior resection point, P = posterior resection point, S = septal resection point, L= lateral resection point.

1A Resection points (border of the necrotic myocardium) are determined with wall thickening abnormality and non-viability signs on cMRI images and expressed as distance from the apex on 3D image. Resection points ont eh antero-posterior view are the followings: A= anterior resection point, P= posterior resection point, S=septal resection point, L=lateral resection point.

1B. Virtual left ventricular aneurysm resection on a 3D pre-operative model.

1C. Circular reduction is performed using the determined resection points on a virtual 3D model. During this process residual left ventricular volume is calulated, which is a critical point in the operative decision making.

1D. Intra-operative picture with the resection points, positioned with 4-0 TiCrone® stitches: A= anterior resection point, P= posterior resection point, S=septal resection point, L=lateral resection point.

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Numbers of complete aortic root reconstruction surgeries within three decades (1982-2013) (Total number of surgeries: 328)

and provide care for Marfan patients living in Hungary. Presently, we care for over 300 patients at our Marfan ambulance. 96 of them received full aortic root and ascending aorta reconstructions. In one-third of these cases, we conducted preventive intervention, aiming to prevent the development of an aortic dissection. The aim for aortic valve retention gradually replaced the Bentall surgery type with the David Tirone-type aortic root and ascending aorta reconstruction with valve retention.

The first Hungarian heart transplantation was conducted at our clinic on January 3rd, 1992. Following this successful surgery, our institution was nominated to oversee and organize the Hungarian heart transplantation program as a singular center. During the last 21 years (1992-2013), 241 adult heart transplantations took place at our clinic. 2012 was the year of success for the HTX program. As a result of changes in organization and approach at the end of 2011 and the beginning of 2012, 30 heart transplantations took place in this year, twice the amount conducted in the previous one. The year 2014 the number of heart transplant patients reached 51.

However, this wasn’t just a sharp rise in quantity, but surgical efficiency grew as well.

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Yearly heart transplantation activity at the Heart and Vascular Center Semmelweis University number of patients calendar year

Our 30-day survival ratio came close to 87% (death rate: 4/30). Our institution rose to a distinguished position among heart transplantation centers with this HTX performance.

Only two dozens of centers succeed this number in proportion among the 266 centers yielding data for the International Society of Heart & Lung Transplantation (ISHLT) register.

Part of the patients participating in the heart transplantation program received ECMO and/or VAD implants, due to post-transplantation primary graft failure, but there has been heart assistance for pre-transplantation patients for support until heart transplantation (bridge-to-transplant), and for post-surgery patients against heart failure (bridge-torecovery). Last year, Hungary’s first fully implantable adult artificial heart implantation (bridge-to-destiny) took place at our clinic, followed by another case the same year.

In 2012, Professor Laszlo Entz headed the Vascular Surgery section at the clinic, as 226 Th e

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The position of the Semmelweis University Heart and Vascular Center among the 266 centers conducting heart transplantation in 2012 (see black arrow) and in 2014 (see red arrow)

Post-transplantation VAD-ECMO implantation, due to primary graft failure

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well as the University Department of Vascular Surgery. Data analysis of the 2012 register maintained by the Hungarian Society of Angiology and Vascular Surgery (Magyar Angiológiai és Érsebészeti Társaság – MAÉT), reveals that our clinic is by far the largest vascular surgery center in Hungary (with 50 beds for vascular surgery patients, with 12 vascular surgeons working in the background). It is especially so with regards to aneurysm and carotid surgeries, of which we conduct about the same amount as the other three largest centers together.

We conducted 2500 open vascular surgeries in 2012, 60% of which were reconstructive arterial surgeries. In line with the international trend, we have more and more emergency surgeries, we had 18% acute interventions. Apart from open surgeries, we conducted 1135 percutaneous endovascular surgeries, together with the extremely busy Department of Invasive Radiology. Close cooperation makes it possible to have daily vascular team discussions, and provide patients with procedures most appropriate in their case. With such a heavy patient load, it is essential to have optimal interdisciplinary communication. At these discussions, the vascular surgeon, the radiologist, and if necessary, the cardiologist, the neurologist and the anesthesiologist jointly decide on the ideal intervention and its timing, on what should happen to the patient. 2012 re-established the unity traditionally existing between different professions at the clinic. The conception of healing cardiac and vascular patients at a joint center, now developing on an international scale, found ideal conditions here, due to century-old traditions.

As the leading vascular surgery center, we conduct close to 40% of all operated aortic aneurysms in Hungary. In 2012, we conducted 135 scheduled open surgeries, due to abdominal aortic aneurysm. The mortality rate of elective open abdominal aneurysm surgeries remained under 2%. The mortality rate of older patients, cumbered with several attendant diseases, unfit for open surgery, thus receiving stentgraft implantation, was also under 2% in 2012. In addition, we are the most busy countrywide center conducting open and catheter-assisted surgeries on aortectasia involving both the thoracic and the thoracic-abdominal aorta sections. We operated 13 raptured abdominal aortic aneurysms in emergency in 2012. For the traumatic rapture of the thoracic aorta, the first procedural choice at our clinic is stentgraft implantation. The procedure is available around the clock, excellent results confirm that the vascular surgeon – radiologist – intensive therapist cooperation is well organized in this clinical case of high mortality rate.

At our clinic, 384 stroke preventive carotid artery stenosis surgeries took place with an open technique in 2012, 96% of which were conducted with eversion endarterectonomy, the rest in shunt protection with prosthesis patch or artificial vein interpositioning.

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Number of stentgraft implantations at the Semmelweis University Heart and Vascular Center after 2000 Note: 18,8% of the interventions were emergencies

The rather rare supraaortic surgeries, such as subclavian-carotid transposition, subclavian-carotid bypass, and extra-anatomic extrathoracic surgeries for the occlusion or stenosis of supra aortic branches, are also part of our practice. The post-surgery neurological complication rate is 2,7%, there were no mortal cases.

If the pre-operational discussion suggested catheter-assistance (266 cases), we conducted stent implantation in filter safeguard in the carotid bifurcation or in the initial section of the internal carotid artery. Together, these (the open surgeries and the endovascular interventions) added up to 650 carotid surgeries. For stenosis or occlusion in the closer proximity to the common carotid, the subclavian vein or the brachiocephalic artery, our first choice is catheter-based, if possible. If not, we conduct an open chest surgery.

We conducted 21 surgeries for thoracic and thoracoabdominal aortic aneurysms in 2012. These are the most complex surgeries in vascular surgery. Another high-mortality disease is aortic dissection, the Stanford B type of which belongs to the realm of vascular surgery, calling for a surgical solution. In this year, we met 14 such cases in acute or chronic form, and conducted open surgeries or stentgraft implantations. Stentgraft implantation with this indication is considered a novelty world-wide. In the open surgery, thoracoabdominal aortic re-fenestration or artificial vein implantation takes place. These surgeries require a well trained anesthesiology team for success, and cardiopulmonary bypass is used if necessary.

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Numeral pattern of carotid surgeries and interventions at the Semmelweis University Heart and Vascular Center

Another example of professional cooperation is the combined carotid and coronary bypass surgery, for which appropriate conditions are provided at our clinic. We conducted stentgraft implantation in 36 acute or chronic cases in the thoracic aorta, and we can choose the best stentgrafts available world-wide. In less frequent, and thus rare cases, involving the visceral branches of the aorta, we successfully applied covered stents, flowmodulating stents, or open surgery solutions (linear, mesenteric and renal arteries).

The most frequent vascular surgery type is for lower limb atherosclerosis, and we conducted 466 of these on the aortoiliac section. In 47% of these cases, we carried out endarterectomy or a hybrid operation with stent implantation, and 53% were bypass surgeries. In this year, we conducted 280 percutaneous interventions for occlusive supraingunial disease.

We conducted 211 infrainguinal surgeries on the femoropopliteal-cural section, and 265 femoropopliteal percutaneous interventions. Crural PTA/stenting took place in 181 cases (often with diabetic patients), we are a diabetic center, and often receive critical diabetic gangrene for limb-saving.

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In 2012, with the aid of our clinic’s local homograft bank, storing frozen homografts, we implanted 10 arterial or venous grafts in situations where the septic state did not allow artificial vein implantation, and the personal veins were not fit for the bypass, the limb would have had to be amputated. As the countrywide center of graft infection treatment, we treat graft infection taking place either here or in other institutions. In such cases, the most frequent solution is the extra-anatomic bypass. This can be axillofemoral, femorofemoral, iliofemoral or obturator bypass (we had 30 such cases in 2012). The graft material was silver impregnated Dacron graft, personal deep femoral vein or homograft as well. A well functioning arteriovenosus fistula is essential for the hemodialysis of chronic renal failure patients in ever growing numbers worldwide. This year, we conducted 98 surgeries of this type, we serve not only our own university’s dialysis center, but complex cases from all through the country. The excellence of our clinic’s vascular surgery section is depicted by the fact that even with a heavy patient load, the vascular surgery mortality rate was down to 1% in elective, open surgeries in 2012.

Professor Béla Merkely, inscribing at the presentation of the Hungarian book about the clinic’s first 100 years in 2012

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In 2012, our clinic celebrated its centennial with the honorable publication of a book depicting its past and present.

This English language copy carries on that work. We would like to introduce this clinic in Budapest, which gave several generations and numberless competent authorities to Hungary and to the world. Building on the wise counsel and undiminished optimism of the forefathers, and being aware of our accomplishments, the clinic’s team of doctors and nurses, under the direction of Professor Merkely, looks forward to the next 100 years with confidence in the future.

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