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Ann Thorac Surg 2000;69:1655-1662
© 2000 The Society of Thoracic Surgeons

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Ralph D. Alley Lecture

The hammer, the sickle, and the scalpel: a cardiac surgeon’s view of Eastern Europe

^a Munich, Germany

Address reprint requests to Dr Borst, Widenmayerstrasse 7, D-80538 Munich, Germany
e-mail: hgborst{at}gmx.net

Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

	Introduction

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 
President Kouchoukos, members of The Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (EACTS), dear friends. Thank you for this splendid invitation. For me this lecture carries special importance, as it is likely to be my swan song to an audience in the United States. I am deeply honored.

My lecture has two parts. The first looks at the continuing travail of our colleagues in Eastern Europe 10 years after that unforgettable moment when the Berlin wall came down. The second part highlights the need to extend a helping hand to them. The iron curtain extended thousands of miles from the Baltic Sea in the north to the Bosporus in the south. Using barriers and bullets, its purpose was to discourage movement and communication between East and West.

	East-west exchanges in cardiac surgery

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 
Initially after World War II, East-West relationships languished, except for professorial commitments to international meetings. In terms of practical surgery, the ice was broken by a group of London surgeons (Fig 1). In 1959, Prof Hugh Bentall and Mr William P. Cleland went to operate at the Moscow Institute for Thoracic Surgery, then headed by Prof Alexander V. Bakoulev [1]. A key figure on the team was Dr Denis Melrose, the creator of the famous British pump-oxygenator. Among other unimaginable hindrances, the machine’s hand crank broke and had to be mended on an emergency basis overnight. Nevertheless, all five Bakoulev operations were successful. Cleland’s conclusion from this excursion was, "The good Lord had little else to do in Moscow except look after us!"

View larger version (147K): [in this window] [in a new window]   Fig 1. Pioneers of cardiac surgery in London during a visit to Russia: (from left to right) Mr William P. Cleland, Dr Denis Melrose, theater sister Phyllis Bowtle, anesthetist Dr John Beard, Prof Hugh Bentall, and pump technician John Robson. (With permission of Prof Hugh Bentall, Henley-on-Thames, England.)

View larger version (140K): [in this window] [in a new window]   Fig 2. The initiators of the first US-USSR program in cardiac surgery, Dr Frank Gerbode (left) and Dr Henry T. Bahnson (right). (With permission of Prof Vladimir Alexi-Meskishvili, Berlin, Germany.)

View larger version (161K): [in this window] [in a new window]   Fig 3. The first Russian partner in the US-USSR program in cardiac surgery, Prof Vladimir I. Bourakovsky, director of the Bakoulev Institute for Cardiovascular Surgery in Moscow. (With permission of Prof Vladimir Alexi-Meskishvili, Berlin, Germany.)

Subsequently, a slowly growing number of young fellows from the Soviet satellite countries went to work in Western university clinics. Interestingly, only a handful were from the Soviet Union proper. Some upcoming Western colleagues were allowed to travel to the East. I was one of them. In Figure 4, taken at the Sklifossowsky Institute in Moscow, I am in the company of Dr Vladimir P. Demikhov, the man who, in the 1950s, first demonstrated the feasibility of canine heart and heart-lung transplantation [4]. At the time of our visit in 1967, Dr Demikhov was transplanting canine heads.

View larger version (136K): [in this window] [in a new window]   Fig 4. Dr Vladimir P. Demikhov (arrowhead) and me (third from left) at the Sklifossovsky Institute in Moscow, 1967.

	The post-Communist world

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 
Before going into details about cardiac surgery in Eastern Europe, I will reflect on the post-Soviet scenario as it exists today. The shadow of the hammer and sickle still looms heavily over that part of the world, although to different degrees. In the core of the old Soviet empire, now called the Confederation of Independent States (CIS), the shadow is most tangible. In contrast, our closer Eastern neighbors, including the Baltic states (which had been Soviet republics), with their shorter history of Soviet domination suffer less in the Communist aftermath. Monuments of V. I. Lenin survive all over Russia. Although Lenin has disappeared from the former satellite countries, other key figures are still remembered. For example, a huge relief of Karl Marx looms over the entrance to Leipzig University. If you ask why these statues were not taken down, the answer typically is, "Because they belong to our history," a history different from Hitler’s or Mussolini’s, as all of their statues have vanished. It turns out that people dare not remove certain monuments.

The reason is apparent from a 1997–1998 survey in several East European countries whose citizens were asked whether they were better off before or after perestroika [6]. The result was that more than half of the people were more satisfied in the period before the tide turned! If one breaks down Communist nostalgia by country, the distribution is noteworthy: The longing for Communism is lowest in Poland and Slovenia (about 30%). It is about 37% in the Czech Republic and 45% in Hungary and Slovakia. The leader in this survey was the Ukraine, where 63% of citizens professed to have been better off during the Communist era. One can safely presume similarly high rates for the other members of the CIS, which were not surveyed. These findings clearly correlate with the changes in the annual gross national product per head among the European members of the former Soviet Union from 1990 to 1997 [7]. Poland leads the list with a growth rate of 4.2%. Slovakia, Hungary, Romania, and the Czech Republic had not changed much. In contrast, the national product had fallen between 3% and 6% in Estonia and Belarus, 7% to 8% in Lithuania, Latvia, and Russia, and by almost 13% in the Ukraine.

The perhaps unexpectedly positive memories of the Soviet period are not only related to economic factors. More important are the ideological ones. The people in the former Soviet realm evidently have not yet struck a balance between two of the fundamental values of the Enlightenment, ie, between freedom and equality. Equality was the prime target of Soviet ideology. Freedom, on the other hand, was regarded as a gift of the ever-caring state. It supposedly guaranteed the absence of material need and unemployment as well as protection from the hazards of disease and old age. Freedom as we treasure it, the liberty of decision making, taking personal risks, and assuming responsibility for our own fate, was discredited in the Soviet world.

It was forgotten by many that the price of this enforced equality was high: lack of productivity, low work motivation, and limited access to everyday commodities, all of which resulted in a very low standard of living for the great majority of people. The breakdown of Soviet rule exposed the built-in failure of the system. In the CIS, state social benefits have largely disappeared, the poor have become destitute, and the rich are openly affluent. Initial attempts at reform in these countries became bottlenecked. As a result, governments have lost trust and prestige both at home and abroad. Distrust is widespread. People are fed up with what is perceived as the rampant corruption of the ruling class. In Russia, the president and his Byzantine "family" of Moskovskye Politiky and big "biznessmen" are still trying to dictate the fate of a country about 13,000 km (8,000 miles) across. It is no wonder a democratic consensus among the people is far off!

When traveling through the countries of the old Soviet Union, one is struck by a dramatic difference between the capital cities and the hinterlands. After the time of Catherine the Great, Moscow replaced Saint Petersburg as the economic and political hub of the empire. Moscow appears to be thriving. Buildings have been newly erected or are being restored, and the traffic equals that of Western capitals. Since perestroika, however, new capitals have appeared including Minsk in Belarus and Kiev in the Ukraine. Although they are less affluent than Moscow, the pattern of centralistic rule remains the same.

What about the people? Like young people around the world, the teenagers crave fashion and fun. The middle-aged population often looks pessimistic and dissatisfied, and the old people, who had grown up as the heroes of work and war, are haggard and show obvious signs of want and deprivation. On the other hand, it is fair to say that people are enjoying their newly gained liberties of speech and travel and even are ready to sue the administration. Price control has been abolished, and the shops are full of homemade items and an amazing variety of Western goods; the endless queues have disappeared. As a result of ever-growing backyard farms, the dachas, there is no obvious lack of foodstuffs. Astoundingly, as in Soviet times, a rich program of high-class cultural events is available even in smaller cities.

Once one leaves the focal points of power, one says good-bye to what we now call the global village. Stagnation and gloom are in the air from Brest-Litovsk to Vladivostok, from the Baltic to the Caspian seas. Housing and residential streets show the effects of long-term neglect, often going back to the Russian Revolution. Lighting and heating are problems, and public transportation is a catastrophe. The dirt on potholed roads and the wreckage lying all around leave a lasting impression on the Westerner. Many industrial plants have broken down, their smoke stacks idling, their conveyer belts rusting away. An example is the famous Lenin steel plant in the city of Chelyabinsk in the Urals, which in better times produced a million chain tractors (a heavy tractor on caterpiller tracks) and 80,000 armored tanks. It now is a museum. The same demise has stricken the scientific institutes. Many of them lie vacant. One high-tech institute in Tomsk, Siberia, survives only by cutting puzzles with its computerized equipment!

Not unexpectedly, there are noticeable differences in economic power within the regions of the old Soviet Union, that are based on, first, the natural wealth of the land and, second, the enterprise of regional governments. Siberia, for example, is enormously rich in oil, natural gas, and metals, including gold. Similarly, the vast agricultural plains along the Dnepr, the Don, and the Kuban, north of the Caucasus Mountains, allow these areas to do relatively well. Their respective governments not only disregard central rule but now sometimes actually oppose it.

When traveling in the former satellite countries, it becomes obvious that the damage to human and material infrastructure caused by the Communist system is far less pronounced. This is particularly true for the countries bordering Western Europe, including the Baltic states, which always had been better off because of their tradition and their continuing contact with the West. Romania and Bulgaria were less fortunate in that respect. In all of these countries, however, the situation has changed dramatically since perestroika. Industry, formerly completely geared to the Comecon (Council for Mutual Economic Aid), is gradually recovering and is producing goods to Western standards. New buildings are going up everywhere, and streets are being repaired. Most importantly, these countries are establishing democratic institutions, which increasingly are winning the trust of the public. Visiting cities like Warsaw, Prague, Budapest, and Vilnius makes one feel at home again.

	Cardiac surgery

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 
At this point I leave my background story and focus on the effects of Soviet rule on science in general and our specialty in particular. The Soviet system totally uprooted the classical Western idea of combined postgraduate teaching and research based in autonomous universities. The universities, including medical schools, were transformed into institutions for professional training, and scientific research and advanced education were concentrated in so-called academies, eg, the All-Union (now Russian) Academy of Medical Science and its Medical Institutes. The purpose of this was to achieve strict control by the state, ie, the Communist party. This system has not changed much in the CIS. Quite in contrast, some of the former satellite states are gradually returning to specialty training and research, mainly university based. This is a painful process in terms of both funding and restructuring, which leaves many people jobless. To date, the transformation is completed only in East Germany, where most academies were abolished. The existing universities were strengthened, new ones were founded, and 133 sovereign scientific institutions outside universities were established [8]. The staggering costs was about 4 billion US dollars from 1991 to 1995 alone—an amount that only an affluent country like Germany could afford.

Surgical training
The structure and the time course of medical education in the Soviet world does not differ fundamentally from those in the West. After medical school and internship, doctors interested in specialty training undergo a graded program of up to 10 years, each involving clinical and research work. During these years, the individual, depending on academic aspirations, can become candidate, doctor of medical science, and ultimately professor. Specialization can take place at any hospital so qualified, federal or regional. Importantly, this system differs from ours in that there is no cardiothoracic specialization. The opportunities for young surgeons to operate, particularly in cardiothoracic surgery, are few because of the large numbers of them and the generally low case load. One attempt at ameliorating this dilemma was to divide cardiothoracic surgery into a host of superspecialties: surgery devoted to valves, bacterial endocarditis, coronary artery disease, rhythm disturbances, and congenital heart disease in adults, children, and infants. The result is an unbearable overstaffing of clinics with doctors who have little to do and few job opportunities.

Centers
The centers performing advanced surgical procedures in the countries of the CIS were and still are administered by either the Ministry of Health or the Academies of Medical Science, and sometimes the Military Ministry of the respective countries. Cardiac surgery is highly concentrated in the capital cities where the major portion of each respective national case load is treated. Only two centers in the CIS carry out more than 1,000 open heart operations a year. In addition, there are many smaller cardiac services under the responsibility of regional governments. Among these centers, 250 to 350 open heart operations annually is considered a high case load. In the former satellite countries, the previous system persists to a variable extent, but cardiac surgery is more regionalized, with several centers operating on more than 1,000 patients annually.

The typical Soviet-style cardiac surgical unit differs considerably from the Western pattern. It often is part of an overall cardiology center whose major focus is conservative treatment and outpatient care. Included in the surgical unit are anesthesiology, vascular surgery and, surprising to us, interventional cardiology. A special group of doctors performs cardiopulmonary bypass. General thoracic surgery is always separate. In the once satellite countries, cardiac surgical units separate from cardiology and anesthesiology are now more typical.

Buildings
The centers of cardiac surgery in the CIS originally had been planned to be quite luxurious even by Western standards. Most of the peripheral centers, however, are in a state of long-term neglect, even though cardiac surgery commonly has a more privileged position. The regional hospital in Figure 5 is a typical example. Often the buildings are run down, the elevators do not work, and the staircases are broken. Patients are crammed into rooms with beds of variable vintage. Sanitary conditions generally are substandard. Modern air conditioning in operating rooms is an exception. Some of the centers never were finished, one example is in Krasnodar, northern Caucasus. There a beautiful 150-bed cardiology center has been ready to go for a decade but lacks an interior. Nevertheless, a few centers measure up to the latest Western standards. Figure 6 depicts the newly finished Bakoulev Scientific Institute for Cardiovascular Surgery in Moscow with its 18 operating rooms equipped with laminar flow cubicles. When fully functional, this huge center, in keeping with the idea of centralization, is supposed to carry a major portion of the Russian case load.

View larger version (134K): [in this window] [in a new window]   Fig 5. Regional Hospital No. 1 in Rostov na Donu (Rostov on Don).

View larger version (134K): [in this window] [in a new window]   Fig 6. The new Bakoulev Scientific Center for Cardiovascular Surgery, Moscow. (With permission of Prof Vladimir Alexi-Meskishvili, Berlin, Germany.)

View larger version (113K): [in this window] [in a new window]   Fig 7. In Volgograd, formerly Stalingrad, a battle-scarred German howitzer stands in a field with a new heart center in the background.

Equipment and apparatus
The lack of modern equipment and apparatus in the operating room and the intensive care unit, so essential for cardiac surgery, is appalling in most centers of the CIS. The typical sight in intensive care units is a potpourri of often outdated respirators, monitors, and infusion pumps from a variety of Western and Eastern manufacturers, their presence often being the results of bargains or donations (Fig 8). Therefore, every center depends on busy mechanical, electrical, and electronic workshops in an attempt to compensate for the almost universal lack of spare parts. The most crucial factor limiting the volume of open heart surgery, however, is the shortage of disposable equipment, including oxygenators, tubing, vascular grafts, cardiac catheters, and especially sutures, all of which must be bought in the West. To ameliorate this problem, disposables are sterilized over and over again. In some units, Russian-made foam oxygenators from the 1960s are still in use.

View larger version (130K): [in this window] [in a new window]   Fig 8. An intensive care unit in a Russian heart center.

Funding
Open heart operations performed with cardiopulmonary bypass and requiring no implants cost $5,000 to $6,000 US in the CIS. Formerly, the state paid for the whole procedure; today that is the exception, although Russia established a Fund for Mandatory Medical Insurance in 1990 [9]. Sometimes, the patient pays a basic fee of about $1,000 US, the hospital carrier covering the rest. More recently, some large industrial companies have established insurance coverage. However, the easiest and by far the most common access to operation for patients is to buy all the disposable supplies necessary for diagnostic and surgical treatment in a downtown store. If a heart valve prosthesis is required, it likewise can be bought by the patient ($2,000 US for a Western-made model and $500 US for a Russian-made model). Patient purchasing of the necessary equipment has prevented the collapse of the operative program in many of the centers visited. Clearly, the severe limitations to providing cardiac surgical procedures must not be blamed on the current economic calamities alone. In fact, the socialistic "free medical care" system always had fallen severely short in this regard. Of course, this was true for all kinds of expensive treatment. The catastrophic breakdown of funding for any medical care in the past decade and the dramatic devaluation of the ruble in 1998 have compounded this deficiency.

As in all other respects, funding of cardiac surgery in the former satellite countries is improving rapidly because of the reintroduction of prewar compulsory health insurance plans. Private insurance also is appearing. The Czech Republic, Hungary, and Poland have made good strides, whereas the more remote once satellite countries are gradually following suit.

Personnel
The quality of cardiac surgery relates to the level of training, working habits, and motivation of the personnel. Visitors to the CIS come to appreciate both the basic knowledge and the professionalism of the senior surgical, anesthesiology, and nursing staffs, which often are quite comparable to ours. Everybody is extremely eager to introduce the newer, more advanced procedures. Sometimes, however, we have noticed conflicts of responsibility among surgeons, anesthetists, pump personnel, and their nonsurgical partners, conflicts that hinder efficient collaboration. Work motivation is often impeded by low salaries, poor housing, and impossible means of transportation. The income of doctors and allied personnel is ridiculously low by Western standards, often not covering even minimal subsistence levels. In addition, salaries sometimes arrive after months of delay. Therefore, to augment their income, many of these professionals are forced to work secondary jobs or to barter for all kinds of goods [9]. Shopping for basic commodities is another distraction. As a result, generally no more than one patient per table per day can undergo operation.

The situation in most of the former satellite countries differs from that in the CIS. With everybody still on the state payroll, salaries have remained far below Western levels. However, housing and commodities are more adequate than previously. Also, the unbroken university tradition makes for clear demarcation of responsibilities, which ultimately creates the efficient teamwork familiar to us.

Operative volume and foci
Open heart surgical procedures in the countries of the CIS has stagnated deplorably since the last All-Union survey of 1989. The 1998 figures for Moldavia, Russia, Belarus, the Ukraine and Georgia were 56, 54, 42, 37 and 22, respectively. (The annual figures for open heart operations in all Eastern countries in 1998 were kindly provided to me by the heads of their leading centers. Professor Valeri S. Chekanov of the Bakoulev Institute, Moscow, who originally had been responsible for the Registry, kindly updated the Russian figures to 1996.) The sorrowful result is that countless people continue to die without ever seeing a cardiac surgeon. In view of the limitations cited, palliation of congenital and acquired heart disease still plays a dominant role.

For the same limitations, surgical procedures were widely performed with the patient under surface hypothermia and are still done that way at the large center in Novosibirsk, where more than 12,000 such operations have been carried out. Large-scale and successful surgical intervention on infants and newborns are performed in only a very few units [9]. Peripheral centers are overwhelmed by valvular procedures (mainly valve replacement) and operations for congenital heart disease. Only a few have gained ground in coronary artery bypass grafting.

Quite in contrast, open heart surgery in most of the former satellite countries is recovering quickly. These are the 1998 figures (operations per million population): the Czech Republic, 627; Hungary, 477; Lithuania, 421; Poland, 342; Estonia, 346; Slovakia, 284; Latvia, 252; Bulgaria, 182; and Romania, 93. Importantly, the output of open heart procedures in most of these countries has risen considerably, as exemplified by the Czech Republic, Hungary, and Poland (Fig 9). They can be expected to reach the present Western European mean of about 800 operations per million [10] within a reasonable time. The operative spectrum in the former satellite countries is approaching that of the West. Notably, there are several excellent centers for the treatment of congenital heart disease in young patients and for cardiac transplantation. Additional information on Russia pertaining to 1997 and 1998 was provided by Dr Vladimir Pridhodko, Chelyabinsk, Prof Valdimir Shipulin, Tomsk, and Dr Kristof Siedlecki, W.L. Gore & Associates, Moscow.

View larger version (15K): [in this window] [in a new window]   Fig 9. Growth rates of open heart surgery in the Czech Republic, Hungary, and Poland, 1988–1998.

	Relief programs

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

Fourteen short-term professorial visits involving 26 sites have been sponsored. Nine professors from Western Europe traveled to most Eastern regions, including the Caucasus and central Russia, where they taught, did consultations, and performed operations. Their main purpose, however, was to evaluate the quality and the future prospects of individual units and of fellowship applicants. Conversely, five professors visited the West. Because of their greater impact, visits of whole teams have gained increasing importance. Such teams of two to five people comprise surgeons, anesthetists, pump technicians, nurses, and sometimes even hospital administrators. Four Western teams have gone to Eastern centers, and 17 Eastern teams from sites as remote as Murmansk on the Arctic Sea and Tomsk in Siberia have traveled to Western Europe. Importantly, many of the professorial and group contacts were mutual and have led to lasting clinic-to-clinic collaboration.

We have staged our first workshop, which focused on topics of special interest to our Russian colleagues in Tomsk. Among the subjects covered was off-pump coronary bypass, the importance of which to developing countries cannot be overstressed. One cardiac and one thoracic workshop is planned for this year. The EACTS has sponsored free access to its annual meetings and to certain symposia for many Eastern European colleagues. Although not the primary object of our program, tons of equipment have been shipped from Sweden and Germany to centers in Lithuania, Russia, and the Ukraine. Finally, we have assisted many surgeons to connect with the Cardiothoracic Surgery Network or CTSNet (http:www.ctsnet.org). Total funding for this program has exceeded $500,000 US: roughly one third of the donations are from major industrial companies, another third from the European Association for Cardio-Thoracic Surgery, and the rest from international philanthropic funds (Fig 10). We could not have succeeded had not these organizations understood the huge humanitarian task at hand and helped magnanimously.

View larger version (23K): [in this window] [in a new window]   Fig 10. Sponsorship of European Association for Cardio-Thoracic Surgery East European program.

In summary, our endeavors to help our colleagues in Eastern Europe have been highly rewarding to all concerned. We have learned to appreciate the unimaginable restrictions under which our friends are forced to work and how much it means to them to be welcomed into the international family of surgeons. Their hospitality has been overwhelming and often quite moving. It has included wonderful dinners, excursions, and cultural events. For those of you leery of traveling to these far-off places, personal safety, transportation, and translation have never been problems.

	Prospects

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 
What are the prospects? For obvious reasons, we in the West cannot rectify the stupendous material deficits our colleagues in the East are facing. They will be overcome only when economic conditions, including health care, are restructured and thriving. This will take patience on both sides, and we must avoid hurting the pride of our colleagues! Our associates in the former Soviet empire have their own remarkable histories in the art and science of cardiac surgery, including many "firsts" in or within our field, dating back to prewar times and continuing to the 1960s [4, 11–13]. Circumstances entirely beyond their control have prevented our colleagues from keeping pace with the West. On the basis of my experiences, I have no doubts that their devotion and innovative energy are fully alive!

Our major role now is to assist our colleagues to overcome the educational deficits accruing from years of isolation. In addition, there are ways to provide material help, including monetary donations and provision of equipment and apparatus. Just think of the vast amounts of unused and used supplies we discard rather than recycle and of the equipment put away only because of legal restrictions. All of this material is badly needed by our Eastern European partners. We have come to know many cardiothoracic centers in those countries in whose future we trust. The EACTS and US-based organizations are ready to make connections with them. The EACTS can be contacted via e-mail: eacts.secretary@mailbox.calypso.net. In the US, the REMEDY group at Yale University is available for advice via e-mail: REMEDY@Biomed.Yale.edu.

In many ways, the present situation recalls the period after World War II when tremendous help was extended by you Americans to us Western Europeans. That aid put our cardiac surgical programs back on their feet in a short time. Importantly, it was granted regardless of whether or when it would pay off. By no means should our present endeavors be considered mere acts of philanthropy. We now live and work in a global village. Our own lives are inextricably bound with those of our less fortunate neighbors. Their future is our future.

	Acknowledgments

 
I extend my heartfelt gratitude to my dear friend Dr Clement Hiebert of Windham, ME, for enriching this lecture with his excellent suggestions and literate critique. I give cordial thanks to Prof Vladimir Alexi-Meskishvili in Berlin, Prof Hugh Bentall in London, Prof Leo Bokeria in Moscow, and Dr Vladimir Pridhodko in Chelyabinsk for contributing valuable illustrations and to Mrs Susanne Czychos, Hannover Medical School, for photographic work.

	References

Top Introduction East-west exchanges in cardiac... The post-Communist world Cardiac surgery Relief programs Prospects References

 

1. McLeave H. Invitation a Moscou. Les preneurs de risques. Histoire de la chirurgie du coeur. Paris: Buchet/Chastel, 1962:117-124.
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3. DeBakey M.E. U.S.-U.S.S.R. symposium on circulatory support and biomaterials. Artif Organs 1991;15:349-434.
4. Konstantinov I.E. A mystery of Vladimir P. Demikhov. Ann Thorac Surg 1998;65:1171-1177.[Abstract/Free Full Text]
5. Borst H.G. Cardiac surgery beyond the Urals. Eur J Cardio-thorac Surg 1998;14:223-228.[Free Full Text]
6. Zulehner P.M. Religion im Osten Europas. Wiener Journal 1999;226/227:10-12.
7. Gundlach E. Vom unterschiedlichen Wachstum der Nationen. Frankfurter Allgemeine Zeitung 1999;139:15.
8. Parthier B. Deutsch-russische Konferenz. Reformen im Wissenschafts-und Hochschulbereich in Rußland und Ostdeutschland. Jahrbuch-annual publication yearbook Dt Akad Naturforscher Leopoldina 1999;44:523-537.
9. Ivanov M. Russia, take heart. Russian Life 1997;5:4-11 (www.russian-life.com-tofc.htm).
10. Unger F. Cardiac interventions in Europe. Cor Eur 1999;7:177-189.
11. Amosov N.M. The open heart. New York: Simon and Schuster, 1966.
12. Bokeria L.A. History of cardiovascular surgery. Moscow: Bakoulev Scientific Center for Cardiovascular Surgery, 1998.
13. Olearchyk A.S. Vasilii I. Kolesov. A pioneer of coronary revascularization by internal mammary–coronary artery grafting. J Thorac Cardiovasc Surg 1988;96:13-18.[Abstract]

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