Losing Heart

An artificial heart saved Vladimir Tsaryev. But more than a million Russians will probably die of heart disease this year. The fatalities are likely to grow amid unhealthy lifestyles and a collapsing medical system.


Vladimir Tsaryev had always thought he was in good health. His job at a military factory inspecting airplane engines was stressful at times, with its demand for attention to detail, but he kept fit by playing volleyball several times a week with colleagues. He rarely drank. His only vices were those shared by the majority of Russian men: He smoked a pack a day and liked salty foods, especially vobla, or jerk fish.


Ten years ago he found himself quickly short of breath and tired all the time. Doctors at the local Hospital No. 6 in Ufa, the capital of Bashkortostan, 1,200 kilometers southeast of Moscow, diagnosed his condition as mild heart disease and prescribed medication. But Tsaryev's ailment only worsened.


By 1996, doctors told Tsaryev he had dilated cardiomyopathy, a condition in which the ventricles are too weak to pump blood throughout the body. His legs became engorged with blood, adding an extra eight kilograms to his taut frame. Tsaryev's swollen heart eventually occupied 70 percent of his chest and pressed hard against his lungs. When he lay down, the weight of his heart against his upper body was excruciatingly painful, and Tsaryev had to sleep kneeling on special cushions sewn by his wife, Tamara.


Like most regional hospitals across Russia, Hospital No. 6 lacked the funding to buy the sophisticated equipment necessary to treat Tsaryev's condition. The hospital's cardiovascular department f the only one in Bashkortostan f had just had its 8.7 million ruble ($1.6 million) budget cut by 60 percent last year and was turning away 2,000 patients a year. Last winter deputy head cardiologist Oleg Ilteryakov and his colleagues were reduced to selling towels and dish cloths to earn some money. Too humiliated to join the hordes of street vendors in their home town, the cardiovascular surgeons traveled to neighboring Chelyabinsk where they hawked their cloths. The doctors could only urge Tsaryev to seek treatment at one of the better-funded hospitals in Moscow.


Tsaryev's predicament f heart disease with little hope of proper treatment f is a common and growing problem in Russia. Some 800 people out of 100,000, or about 1.2 million people, die in the country every year from cardiovascular disease f a broad term encompassing illnesses of the heart, aorta and blood vessels f according to the World Health Organization. That is the third highest mortality rate in the world, after the former Soviet republics of Turkmenistan and Kazakhstan. Some 500,000 Russians are currently in need of heart surgery, according to Leo Bokeria, the Health Ministry's chief cardiovascular surgeon and director of Moscow's Bakulev Cardiovascular Research Center.


Despite some high-profile patients little has been done to change unhealthy diets and lifestyles in Russia. President Boris Yeltsin underwent a quintuple heart-bypass operation in 1996, and last month Duma Deputy Grigory Yavlinsky suffered a heart attack. Many of Russia's best cardiovascular surgeons have fled the country, mostly to the United States, Israel and Germany. Forty former Bakulev cardiovascular surgeons now work in the northern Israeli city of Haifa. And the latest economic crisis can only worsen the poor situation of medical care. "I have a very pessimistic outlook," says Renat Akchurin, the cardiovascular surgeon who conducted Yeltsin's heart-bypass operation. "The field of medicine has itself become an invalid."


Tsaryev, too, would most likely have joined the list of casualties had it not been for a project in Moscow intended to advance the country's faltering field of cardiology. As Tsaryev's wife gathered her husband's records and cardiograms last November to investigate the possibility of treatment at Moscow's prestigious and still well-funded Bakulev Center, surgeons there were looking for a candidate to receive a type of artificial heart never used before in Russia. The Bakulev Center had recently purchased three artificial hearts, called left ventricular assist systems (LVAS), from the U.S. medical equipment firm, Baxter.


A LVAS is comprised of an electromechanical pump that functions in place of a patient's ailing circulatory system and pumps blood around the body. The LVAS is used both as a temporary device to keep a patient alive until he receives a live heart transplant, as well as a longer term alternative to a real heart. Nearly 900 patients around the world have received such artificial hearts, according to Baxter. But all of Russia's 78 artificial heart recipients before Tsaryev were using older models designed as temporary measures.


Doctors at the Bakulev Center justified the high cost of the operation f about $267,000 to save one patient f as a necessity to advance their technology. Russian surgeons last year performed some 10,000 open-heart surgeries, compared to hundreds of thousands of such procedures done anually in the United States. "If we didn't do such kinds of surgery, we would remain in exactly the same position," says Andrei Yesakov, chief cardiovascular surgeon at Hospital No. 6, of installing the LVAS. "We need to keep moving forward."


From among four candidates, Bakulev cardiovascular surgeons selected Tsaryev to receive the artificial heart. By this time, Tsaryev's heart had deteriorated to such an extent that it was in danger of ceasing at any moment. The surgeons felt Tsaryev was the best-suited candidate because a virus in his blood prevented him from receiving a heart transplant, leaving him no alternative but to rely on a device that could assist his existing heart. Baxter paid for Bokeria to go to Belgium and observe doctors install the LVAS, and for Bokeria to practice the procedure on a calf.


Tsaryev was initially afraid to use a device never implanted in a patient in Russia. He only agreed after watching videos of recipients of similar hearts riding bicycles, playing tennis and living normal lives. "I was in such a bad way, I had no other choice," Tsaryev said recently at his home in Ufa. "I was scared, but these people seemed to have recovered."


The surgery, on March 12, was successful, although Tsaryev suffered a serious infection in his abdomen where the artificial heart was implanted. His new heart is powered by a battery-driven motor weighing three kilograms that Tsaryev carries in a small, airtight, waterproof bag slung over his shoulder. The batteries must be re-charged every 12 hours, and when he sleeps, the motor is hooked up to a generator by his bed. The eerie beat of the heart sounds like a loud clock. "I'm sure people talk about me when I pass, but nobody has been rude to my face," said the soft-spoken Tsaryev. "I have gotten used to the noise."


Against Bokeria's advice, Tsaryev continues to smoke, although less than before. Russia's stubborn adherence to a high-fat diet and smoking, as well as a chronic lack of exercise and high levels of stress, have all been identified as key risk factors for cardiovascular disease.


Despite a wider availability of foods, Russians still consume the same amount of butter and sausages as they did in Soviet times, according to the Health Ministry's Food Institute. Doctors often explain to patients how to lower cholesterol levels through diet, but most people are reluctant to spend extra money to purchase the recommended largely imported lower fat dairy products and vegetables. Some experts also think Russians take little initiative in improving their health. "In this country, people are less responsible for their own health than anywhere in the world," Bokeria says.


Smoking is still on the rise in Russia. An estimated 70 percent of adults aged 30 to 39 are smokers, as well as one in 10 youths under age 16, according to the Health Ministry. Smoking is not uncommon among medical professionals. "The first thing I tell my patients is to give up smoking," says Yury Belov, head of the aorta and coronary surgery department at the Academy of Medical Sciences' Surgery Institute, dragging on one of a succession of cigarettes he smoked during an interview.


Heart disease is more prevalent among men than women around the world, but in Russia the difference is particularly dramatic. Some 90 percent of Russian heart patients are men. "They are perfect candidates for a heart attack," Belov says. "Men suffer more as a result of crisis. Woman can cry and let out their emotions, but Russian men, as family leaders, have to keep more inside."


Big budget cuts are squeezing already desperate medical institutions. "The situation is catastrophic. The government cannot bear the cost of heart surgery," says Sergei Nikonov, a cardiovascular surgeon at the Bakulev Center. Tatyana Dmitrieva, Russia's health minister from August 1996 to May 1998, says the government never spent more than three percent of gross domestic product on the health sector during her tenure. "The lack of funding was, is and will always continue to be perhaps the biggest problem confronting any health minister," she says.


Last month the Health Ministry issued a warning that Russia had only a three-month supply of vital medicines f such as heart disease drugs, antibiotics and blood products. About 70 percent of medicines are imported. The Soviet government implemented prophylactic programs for heart disease, such as obligatory screening and campaigns to promote healthy diets and exercise, but none has been carried out in the last three years due to lack of funding.


At the surgery department of the Chazov Cardiology Research Center in Moscow, patients are being asked to bring their own disposable syringes, gloves and most medications. The eight cardiovascular surgeons at Ufa's Hospital No. 6 supplement their 430-ruble monthly salaries by working as medical duty officers. The weekly 24-hour shift requires doctors to be on call to treat any kind of emergency, from appendicitis to a broken leg. There is tough competition among doctors to get on the shift, which pays $100.


Even Russia's top-ranked surgeons receive a paltry sum compared to their Western colleagues. Belov performs on average three open-heart operations a day and earns $300 a month, while U.S. cardiologist Michael DeBakey, who oversaw Yeltsin's bypass, earns $5,000 for each coronary bypass operation he performs.


The little medical financing that is available ends up in large cities. More than half of Russia's heart operations, and 90 percent of children's cardiovascular surgeries, are performed at Moscow's Bakulev Center. Only 57 hospitals in Russia are equipped to perform cardiovascular surgery compared to some 280,000 such medical establishments in the United States. Out of those 57 hospitals, only a handful of urban institutions f namely in Moscow, St Petersburg, Novosibirsk, Nizhny Novgorod, Kirov, Omsk and Chelyabinsk f perform more than 200 operations a year.


In 1993, the government introduced a system of compulsory medical insurance requiring employers to contribute 3.6 percent of employees' wages into federal and regional insurance funds. But cardiovascular surgeons say the system has failed because insurance companies refuse to reimburse the real costs of treatment. "A coronary bypass operation costs $5,000, but they refuse to pay more than $500," Belov says.


Belov's institute has not received any government money for four years, and like most medical institutions in Russia, has begun charging patients for at least a portion of their treatment f a far cry from Soviet times when the state paid for all procedures, including open-heart surgery.


Only 5 percent of the population can afford such costs, and that wealthy pool is constantly poached by Western hospitals. Akchurin says he is often approached by consultants on behalf of foreign hospitals looking for Russian heart patients to undergo treatment in the West. Some consultants even offer Russian doctors a fee for passing on their patients. Akchurin estimates thousands of Russian patients of all illnesses seek medical treatment overseas each year even though the costs are higher. A coronary bypass operation overseas is often 10 times more expensive than it is in Russia.


Despite f or perhaps because of f the challenges they face, Russia's active surgeons maintain a high level of technical skill, according to many doctors. Belov points out that Russian surgeons perform coronary bypass operations three to five times faster than U.S. surgeons, doing three coronary artery grafts f in which surgeons re-route arteries f in 20 minutes. Western surgeons spend about one hour on the procedure, Belov says.


One factor in promoting efficiency may be the amount of practice the surgeons get. In most countries medical students are forbidden by insurance companies from participating in operations, but here there are no such restrictions. Belov performed his first heart surgery at age 26 and has done about 9,000 operations.


Many foreign students come to Russia to take up such opportunities. "In the West, you cannot operate until you are much older, around 35," says Majdi Abdel Hadi, 27, a trainee cardiovascular surgeon from Jordan who is studying under Belov. Hadi recently assisted in a peripheral vascular operation f surgery of blood vessels in the arms and legs f and hopes to do his first open-heart operation within two years.


Nearly seven months after his surgery, Vladimir Tsaryev's new heart is circulating blood throughout his body. His once bloated natural heart has almost reverted to its normal size, and Bokeria believes it may eventually function properly again on its own. Tsaryev recently began driving a car and enjoys visiting his dacha. "I don't know how long I would have lasted," he says, recalling his state before the surgery. "There were no guarantees."