In 1956, the young Ernst Wolner was in his penultimateyear of secondary school and planning to study law. Then

in October that year, the Hungarian Revolution against thecommunist government displaced refugees into neighbouringAustria. A chance visit to the city hospital to visit a familymember opened Dr Wolner’s eyes to the plight of the refugeesand led him to change his mind. He decided to pin hiscareer hopes on medicine.

“It was a Sunday afternoon, and my mother asked me tovisit a female relative,” Dr Wolner recalled. “It was in thedays before easy access to telephones, and when I got to thehospital, my relative had been discharged on the Fridaybefore. So I had some time on my hands and realised fromthe refugees I saw that if I became a lawyer and I ever hadto move to another country, I wouldn’t be able to practice.But with medicine, I could practice anywhere — in everycountry, on every continent.”

As it turned out, this foresight was not required, as DrWolner, who was born just after the start of World War II,obtained his degree from medical school in Vienna, trainedin the Department of Surgery at the University Hospital,and became professor of surgery there in 1981.

“In 1967, there was a new chief of surgery, Jan Navratil, MD,who was very dedicated to research, particularly cardiacresearch, and he said to me, ‘You are my man for the pro-gramme on assisted circulation.’ So in 1968 we started doingresearch on the intraaortic balloon pump (IABP). This was thefirst department in Europe to implant such a device in a human.”

For Dr Wolner, this was the start of a very long and dis-tinguished career developing cardiac assist devices. Thisseemed a logical step, as in the 2 years immediately after

medical school he carried out research on coronary flow andheart function in the university’s departments of anatomyand pharmacology.

Dr Navratil, who encouraged his career in artificial car-diac devices, was a “real mentor,” but Dr Wolner says he hasbeen motivated by all those who work with him in theDepartment of Cardiothoracic Surgery. “By the age of 41, Iwas the head of the department, and my coworkers inspiredme. What I can really say is that the department has a reallybroad spectrum — 50% of what we do has always beeninnovation, implementing new technologies, and we havedone thousands of heart transplants over the years.”

IABP transplants were just the beginning of theVienna programme on assisted circulation. In the 1970s, theteam was testing left ventricular assist devices in calves, andin 1986 they carried out an artificial heart bridge to transplantoperation in a human.

“I wrote a lot of papers speculating how it would be in theearly 1990s,” Dr Wolner said. “With the exception of energytransfer, it has all been realised. At the beginning of theprogramme, nuclear energy was a real high point, and wewere thinking that all the problems of the power sourcewith mechanical devices would be solved by a nuclear-powered battery in the body, which would provide power forthe whole life of the device.” He believes that developing anenergy source that can power cardiac assist devices fromwithin the body is one of the biggest challenges in the field.

In the 1980s, Dr Wolner and his colleagues developedthe Vienna Artificial Heart, a pulsatile artificial ventricle,

European Perspectives in CardiologyEuropean Perspectives in Cardiology

Chain of HopeSome of Europe’s leading cardiac surgeons give up their time to offer hope to youngheart patients in less developed countries around the world. Life-saving operations areperformed, and educational initiatives are undertaken to improve locally provided care. Page f134

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Circulation August 29, 2006

Profile: Ernst Wolner, MDDr Ernst Wolner, head of theDepartment of CardiothoracicSurgery at the UniversityHospital of Vienna, talked toEmma Wilkinson, BSc, MA,about his life and work.

Cardiac assist devices, such as the new, miniaturised HeartWarecentrifugal pump, have been the focus of Dr Wolner’s career.

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which was successfully used as a total artificial heart and leftventricular assist device and provided a bridge to transplantfor patients with terminal heart failure. However, funding diffic-ulties meant the device never became available on a large scale.

“This was 20 years ago, and we were unable to fund acompany to put it into production, so now it’s a device forour museum. The minimum investment for this sort of proj-ect is $50 million, and this is one of the problems in Europe.In the US they have invested much more in their future.”

Currently, Dr Wolner is working with rotary pumps,which, unlike their pulsatile counterparts, maintain continu-ous blood flow through the heart. “We were very luckybecause we were able to work in close cooperation withMichael E. DeBakey, MD, director of the DeBakey HeartCenter, Baylor College of Medicine, Houston, Tex. We arenow a leading centre within this field. I believe rotary pumpshave an advantage over pulsatile devices. They are small,and they need less energy, so perhaps it will be easier in thefuture to have power sources in the body so you won’t haveto have wires protruding out of the skin.”

When asked about the part of his career he is most proudof, Dr Wolner said it was the founding of the EuropeanAssociation of Cardio-Thoracic Surgeons (EACTS) with his

colleague Francis Fontan, MD. Dr Wolner was president ofthe organisation in 1999. It has gone from strength tostrength since its first meeting in 1987, and now an EACTSconference can hope to attract 5000 delegates. He also men-tioned modestly that he was honoured with the EuropeanSociety for Artificial Organs first award for his outstandingcontribution to artificial organs research in 2002.

Dr Wolner has a wife, who is a dentist, and 5 children.He is now 66 years of age and plans to retire from surgeryby the time he reaches 68. But it is unlikely he will stepback from medicine entirely. In fact, he plans to continuehis work as an advisor on Austrian health policy. For thepast 10 years, he has been president of the advisory boardof the minister of health, a task he calls his “hobby.”

“We advise the minister on how health in Austria shouldbe financed. For example, if there is a new therapeutic pro-cedure, or an issue such as vaccination, or how the healthsystem should deal with obstetrics. I have accumulated alot of general information. I will retire in 2 years, and bythen I will have done 45 years of surgery.” He added, “Iwill still use my knowledge in public health, though.”

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Emma Wilkinson is a freelance medical journalist.

There are many children with serious heart conditions incountries such as Egypt, Kenya, Mozambique, Mauritius,

and Jamaica, where cardiology services are limited. A decadeago, the prospect of effective treatment for them wasvirtually nonexistent.

But now a growing number of children from some of thepoorest parts of the world are receiving lifesaving cardiac sur-gery from a group of Europe’s leading surgeons, who give uptheir own time to treat young patients without payment.

Working under the banner of the Chain of Hope, a charitybased in London, United Kingdom, the surgeons operate onchildren in underdeveloped countries. Importantly, equip-ment and training is offered to enable the establishment ofcardiac teams in those countries to continue the work.

The most serious cases are brought to the UnitedKingdom to receive treatment in hospitals such as GreatOrmond Street, the Royal Brompton, Harefield, and Guysand St Thomas’ Hospitals, all in London, United Kingdom.Surgeons taking part include Victor Tsang, MS, FRCS,

MSc, consultant cardiac surgeon at Great Ormond StreetHospital, who, as well as volunteering his services inEngland to treat children, travels regularly to assist treatingthe backlog of paediatric cardiac cases in Jamaica. Sir MagdiYacoub, FRS, FRCS — who founded the charity in 1995 —and Dr Tsang have been helping local surgeon Roger Irvine,DM, MB, DS, (who trained with Sir Magdi in the UnitedKingdom) to establish an autonomous paediatric cardiacservice in Kingston, the capital city of Jamaica, by developingeducation materials, holding teaching seminars for nurses,donating equipment, and training key clinical personnel.

Dr Tsang said, “With the support of the local cardiolo-gists, cardiac surgeons, nurses, and perfusionists, we under-take a wide range of open heart surgery for congenital and

Chain of HopeSome of Europe’s leading cardiacsurgeons give up their time tooffer hope to young heartpatients across the globe throughthe medium of the Chain of Hopecharity, founded by Sir MagdiYacoub (right). Mark Nichollsexplains how the project functions.

Dr Babulal Sethia teaching in Brazil. Training local colleagues in themanagement of congenital heart disease facilitates the care ofmany more children than simply treating patients in England.

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rheumatic heart disease in Jamaica. We see the children weoperated on a year later, and it is most satisfying to seethem running around full of energy and joy.”

Consultant cardiac surgeon at the Royal Brompton andHarefield Hospitals, Babulal Sethia, FRCS, has contributedto surgical programmes for Chain of Hope in Egypt, Mauritiusand, most recently, Brazil, as well as operating on patients inLondon. He explained that the surgical operations cover thefull range of neonatal, infant, paediatric, and adult congen-ital cardiac surgery.

“We are currently focussing on the development of edu-cational initiatives wherever we work, and thereby tryingto ensure that the overseas units become self-sufficientwithin an agreed, defined time frame,” said Dr Sethia.

“Training other colleagues in the care of children bornwith congenital heart disease facilitates the care of so manymore children than would be possible simply by treatingpatients in our own centres in England,” he added. But hesaid there is also the opportunity to learn from the experi-ences of other countries and “potentially bring benefit topatients in our own centre when we return to the UK.”

Without surgical intervention, the children would havelittle hope. “In many instances, the alternative is prolongedincapacity, extra suffering, and premature death. The fact thatso many children can return to a normal quality of life bringsmuch joy to their families and those who care for them,” saidDr Sethia.

Paediatric cardiologist Philipp Bonhoeffer, MD, from

Great Ormond Street Hospital, said that in poor countriesneonates with cardiac disease often never get to a hospital,and die at home. However, many of the children who dosurvive the neonatal period often have relatively simplecardiac lesions. “It is difficult and wrong to deny childrentheir right to life when a relatively simple procedure cansave them,” he said.

He added that cardiac interventional work lends itselfvery well to the environment they find themselves workingin, with basic x-ray equipment and monitors available ineven the poorest countries.

“Furthermore, cardiac catheterisation does not have thesame requirements as surgery in terms of staffing andintensive care facilities,” he said. “Balloon dilatation ofstenotic valves can therefore easily be carried out in con-genital and acquired heart disease. Mitral stenosis in thecontext of rheumatic heart disease is common even in chil-dren and is easily treated,” he explained. “Pulmonarystenosis can be dilated in the classic indication, but can alsobe carried out as a palliative measure in children with cyan-otic congenital heart disease.”

Basically every intervention can be performed in a verysimple setting, he said. “The environment of a catheter lab-oratory also allows for excellent cardiological education incountries where no cardiological services are available.Therefore it can be used as a first step into cardiac treat-ment. Cardiac surgery can then be developed at a laterstage along with the intensive care requirements. This is

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Dr Victor Tsang examines a young patient in Jamaica. He travels there regularly to assist in treating the backlog of cases there.

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how we initially developed services in Kenya andMozambique, where interventional catheterisation and car-diac surgery are now regularly performed.” He added thatthe more important impact is the provision of local trainingfor health professionals.

Dr Bonhoeffer continued, “For example, I developed atechnique of mitral dilatation more than 10 years ago. ThenI taught my Kenyan colleagues to carry out mitral dilatationswithout my help. They have now saved the lives of hundredsof children with severe mitral stenosis in my absence.”

Chain of Hope Executive Director Emma Scanlanexplained that some children are still brought to the UnitedKingdom for treatment and are looked after by host families,but a growing number of missions are undertaken to thirdworld countries to treat children closer to where they live,and to help establish cardiac services in those countries.

Ms Scanlan said, “We send doctors, volunteer surgeons,and nurses overseas to operate on children, and also tooffer training to exchange knowledge and transfer skills,whether technical or clinical. Advice on the managementof cardiac disease in those countries is also given.”Mozambique, for example, had no cardiac services prior tothe charity’s involvement.

The charity began by focussing on congenital heart dis-ease, but is becoming more experienced in dealing with rheu-matic heart disease and more complex cases. Ms Scanlanexplained that diseased and malfunctioning valves arebeing replaced with human tissue valves, and in the case ofmitral valves, these are repaired where possible. The reasonbehind these strategies is to avoid reliance on anticoag-ulants, because these drugs are not always readily availablein these countries, and they require intensive and accuratemanagement. Chain of Hope surgeons are now looking atways of tackling endomyocardial fibrosis, which is a grow-ing problem in some parts of the world.

So what motivates surgeons and other medical staff totake part? Ms Scanlan said, “I believe they feel it is a sensethat medicine, science, and technology do not belong to acertain part of the world, they belong to humankind. It’s not

just about providing services now, but about providingservices for the future.”

A recent mission saw Sir Magdi Yacoub take a team toEgypt. Working with an Italian charity, they were able toequip a children’s hospital in Cairo with an operating theatrefor cardiac surgery and an intensive care unit, and alsohelped to provide further training and experience to localstaff. Ms Scanlan explained the need for such facilities, asEgypt has a huge backlog of patients with rheumatic heartdisease and a high incidence of congenital heart disease.

A mission, typically costing £40 000, normally lastsaround 2 weeks, the first week being for surgical work with15 to 20 operations conducted in that time. The secondweek is for postoperative work, during which the team seesthe children safely through intensive care and can offersupport and training to the local team.

Founder patron Sir Magdi said that in the last 10 yearsChain of Hope has grown significantly in the type of work itdoes and is making a significant difference to the lives of chil-dren who may not otherwise get treatment. Around 1 child inevery 100 in the countries affected are born with a heart defect.Sir Magdi said, “Most of these problems can be corrected byoperations that are performed as a matter of routine in thedeveloped countries. In contrast, if uncorrected, these defectscan cause considerable suffering and premature death.”

Chain of Hope relies on donations in order to providethe £600 000 it needs each year to remain operational. Ifany readers would like to know more, they can contactEmma Scanlan on 0207 351 1978 or visit the Chain ofHope website at www.chainofhope.org.

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Editor: Thomas F. Lüscher, MD, FRCP, FACCManaging Editor: Keith Barnard, MB, BS, MRCS, LRCPWe welcome your comments. E-mail the managing editor atKeith.Barnard@wolterskluwer.com

The opinions expressed in Circulation: EuropeanPerspectives in Cardiology are not necessarily those of theeditors or of the American Heart Association.

The Chain of Hope website relates its history, offers news on thework it is doing, and offers the opportunity to make a donation.

Dr Philipp Bonhoeffer performs echocardiography on a child inKenya. He has taught his Kenyan colleagues a technique for mitraldilatation that has enabled them to save hundreds of lives.

Mark Nicholls is a freelance medical writer.

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European Perspectives

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2006 American Heart Association, Inc. All rights reserved.

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