The Onassis Cardiac Surgery Center (O.C.S.C.)
It is useful to take a brief look back at the previous history of this hospital, unique in Greece, and at the regulations, at least as they were laid down for its operation in the law passed for its founding. There is no way, however, that I am going to attempt a description of the 25 years it has been in operation, apart from what concerns the transplants and the medical service. Besides, anyone who is interested in how the Onassis was set up can refer to the excellent book by the vice chairman of the Public Benefit Foundation (Alexandros S. Onassis), Pavlos I. Ioannides, entitled “And if you are not, you will be….”
In 1977, when the Foundation decided to build, equip, and operate the cardiac surgery center, a long struggle and many fruitless representations to various governments were required before the gift was accepted in 1986. Thus, Law No. 2012/92 regarding the gift was published on February 27th and 8 months later, on October 6th 1992, Prime Minister Konstantinos Mitsotakis accepted the cardiac surgery center on behalf of the Greek State.
It has been more than 30 years since the Cardiac Surgery Center was founded, and if we look back, we see that almost all the good intentions of the legislators have been ignored.
The hospital’s Achilles’ heel was Article 5, referring to the state grant. Since the center offered services of a high standard which, however, the state had underpriced, it was not possible for it to operate without outside financial assistance. Since there was no bequest that would contribute to covering the shortfalls in its operations, it was obvious that at the end of each year the center would be dependent on the goodwill of the current Minister of Health. And so from the day it opened, the center was in a hostage situation. An opinion I expressed quite a few times was that the Onassis started haphazardly and continues haphazardly. The hospital did indeed start under intolerable political pressure. There were no regulations or guidelines; there were not even forms for patient case histories. When, during the first couple of years, I was going back and forth between America and Greece, I chaired the Committee of Medical Records for the completion of the history and physical forms, although hundreds of cases had already been dealt with.
I returned to Greece and took up my duties on April 1, 1996, which I sometimes call a day of ill omen. Up to the end of 1995, when I signed the new contract, I was completely aware of what I would be confronted with. The enthusiasm of the first year had passed and the constant negotiations and backtracking in the intervening 3 years left no room for illusions. And as my friend Tasos Tzamalis, for years president of the Numismatic Society of Greece, very shrewdly put it: “How is it possible in a Greece plagued by a moral crisis for there to be an institution where everything works perfectly, where procedures will be adhered to, and where everyone works with and loves his neighbor?”
The Onassis Cardiac Surgery Center. This bold venture
of the Public Benefit Foundation could have changed the horizon
for health care in Greece, if the state had consented.
The patrician Vice President of the Onassis Foundation, Pavlos I. Ioannides.
From the very first day after my return, I started to mold my division. The most senior was Georgos Economopoulos, graduate of the American system and board certified. As senior associate I had selected Georgos Stavridis, trained in England, as well as Louis Louka, Demetris Zarkalis, and Petros Sfyrakis. We six formed the staff of the first cardiac surgery division which I hoped would work along the lines of an American team. I insisted that I was primus inter pares and that each would manage his own cases, dealing with them according to his capabilities and experience. Of course there would be a common policy in regard to the selection of cases, which would be ensured by the establishment of a weekly conference. There would also be close scrutiny of postoperative follow-up, so, in essence, freedom of action but also control.
I was concerned that everyone participate in the surgery, especially when I reflected on the forlorn faces of my younger colleagues who, I realized during my short trips to Athens, did not operate. Imbued as I was with Lower’s principles that the chief simply oversees and assists, I was determined to introduce them into our division. Since my time at the Hippokrateion, I had formed the conviction that one of the misfortunes of Greek medicine is its slow personal development. After interminable years of scut work, struggle, and being put down, someone may achieve the longed-for senior position and then, at 60 years old, attempt the things he should have been doing at 30. And so, making up for lost time, he turns into a hindrance.
Having the complete confidence in myself, I felt certain I could help a younger colleague to operate. Thus, in hundreds of cases from my outpatient clinic, I gave the initiative to my young associates and everyone benefited. Some became better surgeons, while most just managed to become surgeons because when they started working with me they were in no position to carry out even a simple case alone; even going on cardiopulmonary bypass was an ordeal.
Very quickly our team was boosted by a most able addition to the nursing staff: Maria Kotiou, who started the new practice of liaison nurse, that is, the link between the surgical team and the patients.
This, then, was the team with which we started work. Each day at 7:30 we made rounds of the patients in the cardiac ICU with no exceptions made for holidays, because patients do not know that it’s Christmas or Easter. On the contrary, special care is required on those days when everybody “loosens up.” Our team worked like a military unit, which provoked the mocking comment of a close associate: “We are rowers chained to a galley.” However, the division of labor was scrupulously fair, with equal rights for all in the operating room, depending on capabilities, as happens in the meritocratic American system.
With this philosophy and organization, unfailing and without reprieve, more than 6,500 patients were operated in the following 12 years, covering the whole gamut of cardiac surgery. Our division’s record in the treatment of valve disease was particularly encouraging, perhaps because from the beginning I turned the interest of my coworkers in this direction rather than to coronary bypasses, as is usual in most surgical units.
However, the real challenge and deep satisfaction came from the training of doctors working toward their specialty, when the ministry recognized that we could provide 2-year residency training. Their unreserved support was not only consistent with my own training but was a matter of honor for me, since it had been the principal reason for my break with the establishment of the Hippokrateion Hospital in 1974. So for hours on end, I would sit opposite them at the operating table, helping, encouraging, intervening, correcting mistakes when something was going amiss. This was work of the utmost responsibility but with rich returns when the spasmodic, uncertain movements of the neophyte gave way to ease and later to skill and style. But the process is painful and requires self-control on the part of the teacher, who has the responsibility for the patient.
The Professorship
Αt the beginning of 1997, the University of Patras advertised the position of professor of cardiac surgery, although they were unable to offer full employment because of a lack of infrastructure and manpower. When it was suggested, that I apply for the position, I refused. The purpose of my return to Greece was purely and simply to create a transplantation unit at the Onassis and I had no intention of changing direction. Of course, the attraction of the position at a dynamic, expanding university was unquestionable, with its immediate access to the basic sciences and to research, with the infrastructure of a general hospital and—very significant—with a pulmonary medicine department that would provide patients for a lung transplantation program. In the fall I started to work on my candidacy, on the basis of an affiliation between the University of Patras and the Onassis Cardiac Surgery Center, since the law at the time allowed part-time employment in a university position.
The proposal, therefore, had advantages: the university would very quickly inaugurate its clinical program by using medical, nursing, and technical staff from the Onassis on operating days. As medical and nursing staff were gradually appointed, they would undergo a rapid training course in the specialized environment of the Onassis. Finally, serious cases would be referred to the Onassis safely, without delay, until the university program was fully staffed. But there was also a benefit for the Onassis: it would obtain access to the university’s basic sciences for the compiling of research papers and doctoral theses, and to experimental surgery for the introduction of new techniques. In addition, patients with lung disease would also be transferred to the Onassis so that a common program of lung transplantation could be developed.
Thus, on November 18, 1997, I was elected professor with 18 votes out of the 24 present. As usual, the appointment took a year, so it was not until December 15, 1998 that I took the oath before the provost. Meanwhile, a new law was passed regarding full employment, which created a dilemma: either here or there. In a short telephone conversation, one of my chief supporters expressed his fears that I would “drag” the university into interminable legal battles. I assured him that this was certainly not my intention and the following day, February 9, 1999, I submitted my resignation.
I knew then, and I still know, that occupying a professorial position in Greece is considered the pinnacle of achievement, finally leading to election to the academy, the ultimate “Lord, now lettest thou thy servant depart in peace.” Such a thing was never my objective. I came back to Greece simply to create a transplantation program at the Onassis, and this I did in the following years.
In spite of my appointment and its publication in the Government Gazette, I did not use the title of professor in my subsequent professional career. I would not have wanted it to be thought that I took the title and did not offer in return the services that were expected of me. We had made an agreement for the cooperation of the two institutions—the university and the Onassis—but this did not come to fruition, not just for legal reasons but also because there was not the same desire on both sides.
Administrative Labor Pains
The pains always come first. During my time at the Onassis, they began in the first month but they lasted throughout my term, consuming a great deal of energy and strength which I could have used for pure scientific work. Being administrative, they will perhaps seem boring, especially to those who do not belong to the restricted environment of the center.
As I had been concerned for years in America with quality assurance, which is a kind of self-evaluation of all hospital activities, I was asked by the administration to take charge of the QA committee. This undertaking involved me in the administration of the center.
In 2001, I took over the painful, time-consuming, soul-destroying work of drawing up an operative manual for the Medical Service. This concerned the duty roster of the medical staff and its officers. It was conducted with open procedures and the participation of everyone, soon to be limited to the few who were interested, not necessarily those who were looking to the completion of the task.
At about the same time the ISO-9001 certification was introduced, something new in the field of health care. The process was time consuming and the achievement of the aim owes a great deal to the head of biomedical engineering, Georgos Haloutsos, as well as to the head of the quality assurance office, Emer Ronan Asimakopoulou. This system demands periodic checks and the functioning of a permanent Committee of Quality Assurance, of which I was president until my departure in 2008. This was responsible work taking long hours from the free time of a team of dedicated staff—administrative, medical, and nursing—with no personal advantage to themselves. Within the framework of this system, a permanent committee of mortality/morbidity operated, which ensured the necessary control of medical and nursing activity and protected not only the patients but also the institution from future legal entanglements.
However, the most serious crisis concerned the transplant program. From 1996 it continued with everincreasing intensity until the final explosion in 2004. It all began in September 1996 and shortly a new director of the pediatric cardiac surgery division was selected, to the general satisfaction of us all. Although the job advertisement had referred only to pediatric cardiac surgery and stated that any experience in transplantation would be deemed an advantage, the text of his contract included certain changes. It specified that he would perform his duties as director of the fourth cardiac surgery division that didn’t exist in the center’s bylaws. His duties would include transplants on patients under the age of 18 or with congenital heart disease irrespective of age, as well as the right to take on surgical cases of acquired heart disease, according to the decisions of the board. In essence, therefore, this would be the probable creation of a second adult transplant program under the same roof, unheard of in the annals of transplantation.
Going over the facts and the documents up to 2004 again does not help this narration, just as the dispute not only did not help, but actually wasted the center’s precious reserves. This pointless, excessively time consuming and financially draining decade-long dispute came to an end in December 2008. It could have been avoided with rudimentary attention to and respect for the bylaws and existing contracts. In such confrontations there are no winners or losers. The only real loser was the Onassis Cardiac Surgery Center and, by extension, our patients.
I had once suggested that the way in which the OCSC was administered should someday form a separate chapter for students of the health professions. Indeed, I even suggested a title: “How a hospital should not be administered: the case of the Onassis Cardiac Surgery Center.”
State of Siege
With the elections of 2004 and the change in the political scene, it was certain that the center’s board of trustees would change. In any case its term in office was due to expire that year along with the contracts of all medicine directors.
Shortly after taking up its duties, the new board under Professor Ioannis Papadimitriou announced its unwillingness to renew the contracts and a plan to advertise the 12 senior positions. A memorandum sent in protest by the medical service in April 2005 emphasized that these proceedings were a disgrace. This climate of uncertainty continued until July 2006, when the board of trustees finally deigned to grant the remaining time up to the end of 2008.
It had simply postponed the confrontation for 2 years. Thus, in December of the same year, a decision was taken regarding the obligatory retirement of medical personnel at the age of 70, but this was kept secret, the relevant extract being sent only to the legal counsel and the director of the personnel department. The medical service was not informed, nor were any of the directors most closely concerned because they were approaching the age limit. It was the ace up their sleeve which they used when the time came. And let it be noted that the center’s bylaws made no mention of a retirement age.
At some point during 2005, it was announced that the “on-call” availability of the transplant coordinators was being abolished and that after 3:00 in the afternoon there would not be anyone to deal with the problems of our transplanted patients all over the country or to take calls from the transplant organization about the offer of a donor. In order to make use of a graft, two coordinators are required, one for the retrieval team and one at the center coordinating the doctors, nurses, and technical staff involved in the procedure. I made repeated personal appeals to the administration and wrote memoranda until they made the counteroffer to create a shift system, that is, for the three coordinators to work 8-hour shifts to cover the 24 hours. This was a laughably amateurish plan because, as the “boss,” the director of nursing, quickly proved, its application would require three more coordinators, in which case economy would go out the window! In the end, I was obliged to resort to larger means, informing the board about the ISO-9001 certification. As was clearly written in the directives, the “necessary resources” included the 24-hour availability of the coordinators via “on-call.” Thus, faced with the possibility of creating problems with the hospital’s certification, the administration was forced in the end to reinstate the on-call system after a delay of 2 years.
However, this apparent calm did not last until the end. In mid-May 2008 I was informed by the transplant supervisor of the order of the chairman of the board, which had been conveyed via the director of financial services, that from now on we would not use the private Learjet aircraft “for economy reasons.” We would therefore have to use the much slower C-130 of the Air Force, which could easily leave us in the lurch as it sped off on some other urgent mission, and we had some experience of that during the first year of the program’s operations. I was not at all sure that economy was at the heart of the decision and I passed over the fact that the administration had not had the decency and the courage to inform me, the one in charge of the program, directly about any decision it had come to. As I was bound to do, I informed the board in writing, with all the resolve required by the seriousness of the matter, that “I was not prepared to endanger the security measures as far as the preservation of the graft was concerned, by using a slow-moving aircraft and exceeding the acceptable ischemia time.” If, in spite of this, the board insisted, I would be obliged to ask for the suspension of the program and inform the National Transplant Organization and the Ministry of Health to that effect.
I had no doubt about the adverse reactions of the board, as expressed in its 403rd Council Meeting: “The board, after expressing its displeasure about the tone of the letter, would like to make it clear that under no circumstances does it wish the transplant program of the OCSC to be discontinued.” When everyone returned in the fall, the matter had already aroused interest in the daily press. They were expecting changes in the Onassis transplant unit, and sure enough the board of trustees took steps to advertise the director’s, i.e., my, position. This was published in the newspapers on September 25, 2008. They hadn’t even bothered to consult me, the person in charge of the program, regarding the qualifications of the candidates or to ask me for assistance in drawing up the announcement.
The final date for the submission was November 28, 2008, while my contract was due to end on December 31st. There was therefore not even the briefest time to study the curricula vitae or to interview the most promising candidates, necessary, of course, in organized medical circles interested in making choices based on merit. Haste, therefore, and haphazardness, on top of ignorance. Consequently, the board was moving toward replacing me with somebody—anybody—and as a senior board member said: “It doesn’t matter who comes. What matters is who goes.” Thus, against all my principles that one does not apply for a position in which one has already made a mark, I did so. I emphasized in the memorandum to the board that “I am forced to act to prevent a candidate lacking the necessary qualifications from taking my position.”
My application alarmed the board and I was summoned to a plenary meeting where I was pressed to withdraw it. Then they announced for the first time that a decision had been taken 2 years earlier making the age limit 70 years. Only recently the relevant extract of the 372nd meeting of the board of December 13, 2006, came to light. Of course, my counterargument was that such a decision had never been made public and that, in any case, why hadn’t they included an age limit in the advertisement of the position? Was it perhaps because this was not provided for in the bylaws?
Of course, all this fell on deaf ears. In retrospect, the proposal came from the Foundation, as President Antonis Papadimitriou stated years later in 2011.
The Transplants
The transplant program was of course organized along the same lines as the Baylor program and the coordinators, Chrysoula Louri and Demetra Kollia, who had trained there, made sure that the technical know-how and the protocols were transferred to our unit. They were first rate at their jobs and the program owes a great deal to them, not only for the groundwork they laid but also because for a year and a half they put up with taunts and malicious teasing that their director “would have the last laugh” and would never come to the Onassis. Apart from the coordinators, my immediate associates were the cardiologists Stamatis Adamopoulos and Nasos Manginas, with postgraduate training in America, and Georgos Karavolias, who had trained at Harefield.
A word about the philosophy and the structure of the program: it was to be based on nonprofit principles for everyone and the crystal clear allocation of grafts. Patients would be selected by a committee in which, apart from the regular medical staff, the specialty consultants and the essential transplant coordinators would take part. The criteria were those established internationally by the cardiology societies and the International Society for Heart and Lung Transplantation. Similar strict specifications would also apply to the acceptance of a graft. Above all there would be teamwork and group decisions. The candidate would be thoroughly vetted by the 20 members of the selection committee, from the cardiologist to the psychiatrist, who countless times saved us from taking a disastrous step. Thus, the decision to accept a candidate was collective, the product of experience and the viewpoint of each of us.
From the outset, the only aim of the program was to serve the candidates on the list. Our philosophy was simple: a transplantation procedure was carried out if the donor matched the recipient on the list without our having to manipulate things to bring him in line with the offered graft, simply so that there would be another operation. As I was constantly reiterating: “Our program does not just stitch hearts.” If the graft is suitable, that’s fine. If not, let it go to another candidate, part of another program, even to another country. In short, the program does not work like Procrustes’ bed.*
*A murderer who would place his victims on a bed and “lop off” what overhung the ends (head and/or legs), killed by the hero Theseus.
What did the Onassis program aim to offer? For the patient to come out of the surgery with a new heart at least 90% of the time. That he should be alive at the end of the first year in 85% of cases and alive after 10 years in 50% of cases. We aimed high, and the future would show whether our expectations were realistic.
In order to serve patients who had already been operated on at Harefield and enable them to avoid the hassle and also the expense of having to go there, even for insignificant problems, we took over their follow-up at the Onassis. In this way, from the first day our team had patients who would help them consolidate what they had learned in training.
The first transplant after my return—the program’s second—took place in May 1996, and “dear old Mrs. Vasiliki,” as we fondly called her, caused us problems with her persistent episodes of rejection and then the collapse of her spine because of the large amounts of steroids she was taking. Her case was memorable for two reasons. First, when we went to the ICU to retrieve the graft, we realized that the donor’s pressure was going up and down like a yo-yo even though she was being given vasopressors and fluids. I asked Demetra to stay with the donor and she quickly informed me in great distress that the doctor in the unit was slowing down the drip, presumably to bring the pressure down and to make sure that we would not be in time to go to surgery. I therefore made Demetra a permanent fixture by the bed and thanks to her presence we managed to retrieve the organs. I realized then that there was “opposition” to organ donation from some people within the units who for religious or other reasons believed that the donor was “alive” until the heart stopped. The second important reason was that antilymphocyte globulin, necessary for Mrs. Vasiliki’s survival, was temporarily unavailable in Greece. We requested supplies from America but were met with a complete refusal due to bureaucracy. So as not to lose the patient, I flew to Dallas myself, where a sufficient amount of the serum was ready and waiting. The next day I returned to Athens with it. Mrs. Vasiliki got over her episodes of rejection and went back to Koroni, where she lived for 26 more years.
In total three transplants were performed in 1996 and four more in 1997. The program, as I had predicted, would not increase dramatically, not just because there were not many donors and there were two other active programs—at the Evangelismos and the Papanikolaou—but because the number of candidate patients was negligible. The prejudices of our colleagues at other hospitals had immediate repercussions on our referrals. Besides, the programs that had preceded that of the Onassis, in spite of their praiseworthy attempts, had not achieved a survival rate of more than 50% after 1 year. Statistics had not yet been circulated, but news spreads quickly if a new treatment is successful and in this case we heard that half of those who had been transplanted did not do well. And so the temptation was great to accept candidates who did not come up to international specifications, in order to compile a waiting list. Such candidates, even if they survived the surgery, would not have survived long-term because their other organs and systems were already irreparably compromised.
At about the same time, the new president of the National Council on Transplantation, Professor J. Vlachoyannis, decided to bring the legal situation of transplants in Greece up to date. On his initiative, a committee was appointed on which I served under Georgios Koumantos, the revered law professor. The most impressive personality on the committee was the president. Of imperial bearing but with a Doric economy of speech, he provoked amazement with the straightforwardness and clarity of his decisions.
Almost all the transplantation establishment attacked the law, for various reasons. The big sticking point was that with the creation of the new National Organization for Transplantation, criteria for the distribution of organs were introduced and so the various units would no longer be able to act independently, allocating the graft to the candidate of their choice. They had to obey the orders of a central system that determined which candidate on the list would have the graft. The outcry took the form of a crusade and I wrote an article on the subject for the Kathimerini newspaper, entitled “Mayhem.” I argued that our law was more liberal than those imposed upon donations and that the paucity of grafts was due to the fact that a certain section of the medical world for various reasons refused to cooperate. I asserted that no regulation can force the doctors of an ICU to arrive at the diagnosis of brain death if they themselves are not persuaded and did not want to. Corpses will continue to be ventilated until it is certain that the heart has stopped, by which time the organs will not be suitable for transplantation.
From time to time, it has been said by certain rumor-mongers that the Onassis did “easy” and “selected” transplants, hence the superb results. If we look at the numbers, of the 73 patients, 54 were high risk, as they are called. As far as the “selected” cases are concerned, the critics know that since the 1970s the choice has been inextricably entwined with the graft. High-quality hearts are few compared with demand, and that is why they are offered to the biologically fittest candidates on the list. Not unusually, however, the longed-for heart does not appear, while the candidate recipients deteriorate rapidly. For those selected because of their excellent condition, it is then necessary to take a risk even with a graft of inferior quality if they still have a chance of recovering. The following case speaks for itself.
Twenty-seven-year-old Eirene, who was hospitalized in 2002 for cardiomyopathy, was intubated, with an intra-aortic balloon pump and a continuous infusion of drugs. She was on the emergency waiting list but a donor did not appear, in spite of her father’s desperate pleas in the mass media. During the next few days she came down with pneumonia and worsening kidney and liver function. In other words, she was reaching the stage of multiorgan system failure, which is an absolute contraindication for transplantation. The end could not have been far away when a graft from a middle-aged donor in Thessaloniki became available. This was not suitable for such a young girl but it was now a matter of life and death. Without delay we retrieved the graft that unforgettable Saturday night when our return from Thessaloniki at midnight coincided with the exodus of the Athenians and the roads were jammed with cars. Fortunately for Eirene, there was at the time a specially trained police unit with fast cars.
The operation went well, although Eirene suffered all the complications described in the textbooks, including a brain hemorrhage, from which she was saved by the timely diagnosis of our future coordinator Eirene Kitsou. She was in the hospital for a total of 115 days and when she was discharged there was a special farewell ceremony on the seventh floor, where the whole center, as well as the chairman, Professor Stephanis, wished her good luck. Also present were the police officers who had contributed so much to the timely conveyance of her heart.
Accepting high-risk patients was not the only danger, though. Equally significant was the danger that the graft would not work, even from a young person, because the care of the donor until the retrieval of the organs was below standard. The most usual reason was the overuse of vasopressors to maintain blood pressure, but these can damage the myocardium. The proof is that in 20 transplants, mechanical support was required for several days until the graft recovered.
The case of Nikos, the 35-year-old engineer who, although he was working abroad and could easily have chosen any European program yet entrusted his life to the Onassis, eloquently describes the problem. The donor we were offered, 23 years of age and an athlete, could be described as ideal. However, due to his injuries, he had been infused with huge amounts of drugs for low blood pressure which, it turned out, had damaged the myocardium. So after implantation the graft remained immobile, as if in the morgue. An hour passed, 2 hours, and it wasn’t until the third hour that a slight fluttering began. I saw the disappointed faces of my associates, surgeons and anesthesiologists, who foresaw failure. But I saw again in front of me Cliff Hamilton and the “domino” heart, which had needed hours to recover. Of course, the present situation was much worse because the heart wasn’t even contracting. I decided that we would fight to the end.
Rotating my co-workers, I sent some of them for a break while others stayed with the patient on the heart-lung machine. Every half hour the patient’s condition was checked but it was 4 hours before the heart made a few feeble twitches. We stayed on bypass for more than 7 hours until the heart took over and was able to support the circulation. In spite of our initial difficulties, our transplanted patient did wonderfully well and later joined with other like patients to found the “Synechizo” (I Continue) Society, of which he was president. This was the program’s 23rd transplant operation, a historic event that proved once more how persistence is rewarded—Harken’s additional 5%.
Even the nonspecialist can understand, therefore, that acceptance or rejection of an offered graft is the most important link in the transplant chain. That is why in the 74 cases I made the choice myself, going to the donor’s hospital.
The year 2003 was a landmark for the transplant program because for the first time in Greece an “artificial heart,” in reality a ventricular assist device, was implanted into a patient who later received a transplant. Attempts to supply mechanical support until a graft could be found had been made in Thessaloniki by the cardiac surgeon Panagiotis Spyrou, but in the end the so-called “bridge to transplantation” had not been successful. In our case, Mr. Loukas, 63 years old with coronary artery disease, was transferred from another Athenian hospital in a state of shock. His doctors had told his wife: “You will take him to the Onassis to die.” We had already had a short practice in the animal lab. I had entrusted Petros Sfyrakis with the responsibility for this new technique and he efficiently perfected it. Nine months later, we brought Mr. Loukas back to the center to remove the device and give him a new heart. He returned home, making history as the first heart transplant recipient in Greece after mechanical support. Many others followed him in the years to come. As was absolutely fair, the credit went to Petros Sfyrakis and the patient’s cardiologist, Nasos Manginas, at a press conference at the center.
Already from the end of 2004, there were discussions between cardiac surgeons and cardiologists in other hospitals to the effect that heart transplantation was “a thing of the past” and that the age of mechanical circulatory support (M.C.S.) had arrived, with the obvious desire of the interested parties to inaugurate a program for the implanting of devices. They overlooked the fact that the device at that time did not constitute a permanent cure and for that reason should only be used in patients who were candidates for transplantation and on a waiting list. Something else that they were not aware of—which many others are still not aware of—is that the device requires monitoring, about as much as that required for heart transplant recipients.
These truths I summarized in another article in Kathimerini in December 2004, entitled “Heart transplants or machines,” referring the reader to the double meaning of the word “machine.” Even with these slip-ups that reduced the number of candidates on our list, the Onassis proved itself to be a pioneer and a leader, not only in transplants, but also in the implantation of assist devices. Up to the end of 2008, we implanted 54 devices of different types, with Petros Sfyrakis the surgeon for most of these.
The year 2005 was marked by the death of 12-year-old Demetris from Rhodes, the boy with the huge, expressive eyes and the ethereal smile, who waited for a year tied to a pump suitable for his size. He had aroused the interest of the whole of Greece after the visit of Archbishop Christodoulos and Minister of Health Nikitas Kaklamanis. In the early morning hours of July 5th, the round of Athens by bicycle, dedicated to Demetris, was to take place, when one of the connections in the device broke and the battle was lost. So, I wrote a further article for Kathimerini, prompted by this tragic event, in which I again underlined the fact that “there is widespread fear among relatives of a medical error as to whether the brain-dead patient has really died … and that this was why certain of my colleagues did not even bother to approach the family. And so a potential donor ‘silently’ disappears, without the tests for brain death specified by law being carried out.” Again there was no reaction.
At that time, however, in 2004 and 2005, without being able to imagine the consequences, we made two fine investments in the future when we transplanted our beautiful 30-year-old patient, Zoe, and our doctor, the 25-year-old Maria. They subsequently both became mothers, although we had warned them about the possible dangers in changes to their antirejection drugs.
While our program was making progress, the departure of two directors, Christos Lolas and Panagiotis Spyrou, meant a gradual reduction in the activities of their programs at the Evangelismos and the Papanikolaou Hospitals. The National Transplantation Organization, therefore, decided not to renew their licenses in 2003. Without any thought of monopolizing transplants, I could not see how those programs, with a 30% survival rate after 5 years, with the same staff and without their leaders, could achieve better results.
Survival at the Onassis is 40% better at 5 years, compared to the Evangelismos and Papanikolaou programs.
Paul, first heart transplant patient…
…and Gene, first lung transplant patient,
with the vice president of the Public Benefit Foundation, Apostolos Zambelas, at the Onassis. They were invited by the Foundation to promote organ donation (2000).
The transplant is in the center.
The Specialties are the satellites.
The first five Onassis transplants.
Eirene, the face of fortitude. with the police officers who brought her new heart (2002).
He who persists conquers. Nikos, president of “Synechizo”, in Sinai.
The 7-hour shutdown of his heart (2002) is history.
Anne E. Dierlam, R.N.,B.Sc. The former BUMC Transplant Coordinator set up M.C.S. at the Onassis.
The Berlin Heart Bilateral Support Pump.
Mr. Loukas, the first successful bridge to transplantation in Greece,
using a HeartMate 1 left ventricular assist device (2003).
The defeat of time. Demetris waited for a graft with rare courage,
tied to the machines, but fate did not smile on him (2004).
The book about the tragic loss of the young Australian
who became a donor in Greece thanks to his father’s generosity (August 2008).
“Few transplants, mediocre survival”. This adage was demolished by the Onassis figures (74 transplants, 94% 1-yr. survival).
Ten-year survival for heart transplantation at the OCSC, BUMC and ISHLT.
Zoe, transplanted in 2004, gave her son the name of the donor of her heart (2012).
Maria, transplanted in 2005, with her daughter (2012).
Vangelis, the first heart retransplant in Greece(2008).
In spite of all the previous adversities and continual problems, the program took off in 2008. Through the end of June, 11 transplants were performed, among them two lung transplants, all with complete success. The year 2008 was also significant for the first retransplantation performed in our country, on 50-year-old Vangelis from the island of Aigina. We had given him a new heart in 2003 and now he had chronic rejection. Without another operation he would be facing certain death. Vangelis had a special emotional connection with me because after his first operation I had spent a nightmarish weekend with him in the ICU, while at the Hygeia Hospital Kostis, my childhood friend from Kephallinias Street, was departing this life. On Monday morning, Vangelis was out of danger, whereas Kostis was breathing his last without me being with him.
In the end the great publicity and the recognition of the program was due to the heart transplant of Kostas Gribilas, the 30-year-old Greek-Australian journalist. Because of his cardio-myopathy, Kostas had been given a left ventricular assist device in February 2008, but by August he was losing ground because of persistent arrhythmias that were interfering with the function of the device. We were becoming seriously worried when fate took a hand, if we can thus describe the tragic loss of the young Australian, Doujon Zamit, whose fatal beating in Mykonos caused an uproar all over Greece. The 20-year-old was brought with very serious head injuries to Henri Dunant hospital, while press and television caught fire.
The first suggestion that this unfortunate young man could become an organ donor was made by Anne Dierlam, our consultant for the devices, since she had been a transplant coordinator at Baylor. Anne worked with us with unprecedented self-denial for 5 years and the program of mechanical circulatory support—”artificial hearts”—owes a great deal to her American way of working and the system she introduced before returning to her own country.
Τhe young Australian was a potential donor but, understandably, his father, apart from being devastated, was beside himself with fury over what had happened to his son. There was no question of talking about the donation of organs. Here good fortune intervened in the guise of E. Krikeli, my old junior resident at Malden Hospital in Boston, who had also offered her son’s organs after his fatal motorcycle accident. She undertook to talk to the tragic father. Ηe gave not only his son’s heart but also his other organs. Everything went like clockwork, and during the months that followed we had the opportunity to meet the distraught parents of Doujon and to thank them from the bottom of our hearts for the gift of life they had given to Kostas. That August, the program carried out four successful transplants without, of course, vacations.
Indeed, 2008 was our year of recognition, with 19 transplants: 16 hearts and 3 lungs. For the first time, having a substantial number of candidates on the list, we were in a position to accept all the donations we were offered. By the end of the year, we had performed a total of 74 heart transplants—of which one was a retransplant—and six lung transplants. When we drew the graph of survivals, it was one of the best—not just in Europe but world-wide: in the first year it reached 94%, that is, it exceeded the international average by 10%. After 10 years it was 70%, with the international survival being only 50% of the transplants. Of the 74 transplants performed at the Onassis, 70 patients went home, a record indeed, thanks to the successful matching of recipient with a suitable donor. It should be noted that survival at the Onassis during the 12 years was 30% better than that of Baylor, in spite of the known superiority of the American system, because of the difference in long-term follow-up.
A year later we published our results in the journal Transplantation Proceedings, establishing the Onassis program internationally. In the fall of 2010 at the center’s international conference, Dr. Robert Kormos, head of the University of Pittsburgh program—one of the three or four biggest and most recognized in America—congratulated me, saying: “I didn’t know that Greece had a program of such specifications. Your results are better than ours. Our survival rate never exceeded 85%.”
Kostas turned into a goodwill ambassador for our program, and his appearance with Poppy on Vicky Flessa’s TV program, At the Extremes, caused a great stir. The journalist also presented our program at the beginning of December and without doubt that broadcast, with its repeats, made it more widely known and recognized beyond the borders of Greece. I admired her preparation both in research and in the classification of the wealth of material that concerned not only the Onassis program, but also what had come before at Baylor. It was as if she had not chosen it for her program but for the writing of a book. It was journalism of the highest standard. The presentation was superb, the questions shrewd and focused. The whole program exuded organization, care, and good taste. I knew, I felt it, that that evening we had reached the pinnacle and that this was the swansong, not just of my own career, but also of the transplant program.
Anne Dierlam, a few years later, with Sir Magdi at a M.C.S. conference.
The Final Curtain
With the arrival of 2009, we received important, if fleeting, satisfaction with the “Life’s Excellence” award of the ANT1 broadcasting group, thanks to the generous initiative of journalist Vana Marketaki. We were soon brought down to earth by events, however, because developments for the succession were being closely monitored, as was to be expected, by the “Synechizo” society of transplant recipients. Its activities accelerated when it became known that on the final day of my extended contract, March 31, 2009, the board of trustees would go ahead with the election of the new director. A few days earlier in the presence of the chief of staff, the chairman confided to us that the applications received so far did not come up to the board’s expectations and that a new advertisement was planned. It was now obvious even to the board that they had gone ahead with advertising the position without there being a viable successor. In other words, they had “put the cart before the horse.”
I therefore made the counterproposal that they should proceed with promoting both my deputy directors, Stavridis and Sfyrakis, to the position of director, thus creating a “mini multidirectorial” system. In a letter to the board that I wrote immediately after this, I explained that “the combination of the two as directors is indicated since on the one hand Dr. Stavridis has distinguished himself for his organizational and teaching abilities, whereas Dr. Sfyrakis is the only transplant surgeon, apart from the writer, in Greece.” I added that “under these circumstances I would be willing to stay on, with my former subordinates having clearly defined responsibilities to assist, in order to ensure the smooth running of the department and the unit.” I did not fail to emphasize in my recommendation that “the combination of two directors is advisable,” since “any alternative solution regarding these two candidates would mean a lack of either crucial experience in transplantation or of useful organizational management.”
It should be noted that a month earlier, in February 2009, I had made a point of saying in a letter to the Onassis Foundation that “of the candidates for the position of cardiac surgeon no one has all the requirements of the head of the division, and especially of the transplant program. Undoubtedly, my two deputy directors are more suitable as together they fill the gap. If, however, one is chosen over the other, the division and the program will only be half as effective.”
And so when the board, tight-lipped and white-faced, met on March 31st, they found the place besieged by 50 or so people outside the boardroom. Invited by the board to suggest a solution, I asserted verbally what I had already written: the promotion of my two deputy directors. I also offered to stay in whatever capacity the board wanted until they “could find their feet.” So on April 1, 2009, the anniversary of my arrival at the Onassis 13 years earlier, a new day dawned for the department and the center’s transplantation unit. My two associates both took up equal positions and I stayed on for a few months as a special adviser to support them in their first steps.