Heart failure is the leading cause of major hospitalisation. The ageing population and improvements in medical procedures are both factors that mean several forms of heart disease (valvular, coronary and hypertensive) end up going beyond acute phases and result in heart failure.

Though the mortality of patients during hospitalisation is not very high (4.7%), it is worrying that, once they have been discharged, the rate of readmissions and morbidity and mortality are high (50% mortality 18 months after discharge).

Our basic objectives are, on the one hand, to improve the quality of life of patients with heart failure, reducing the number of admissions, readmissions and trips to the Emergency Ward, and, on the other, to apply a protocol for medical action. This involves optimising care resources and thereby reducing the financial impact of the disease. It also means incorporating the latest technologies, depending on the needs of each patient.

The opening of a day hospital has been key. Its functions are: to monitor all patients discharged from the Hospital having suffered heart failure, once the criteria for entering the Programme have been met; to make it easier and faster for patients to access the Unit in case of decompensation or acute episodes, eliminating barriers to access. Communication with the consultation and advice line has also been improved, along with drop-in services during office hours at the day hospital, both for patients who are within the Programme and their relatives and the professionals from primary care centres.

Finally, the Unit offers an open outpatient clinic for patients who have been discharged from the Hospital as well as for those who can be referred to primary care centres, to see either doctors or nurses. The doctors: perform a rapid diagnosis of heart failure syndrome, optimise treatment and monitor patients admitted or patients attended to at the day hospital. The nurses: educate patients and their relatives in the standards of care for patients with heart failure and provide regular home and telephone contact.

As heart failure is a condition that transcends any single health field, and the Hospital is just one of the ingredients in addressing this type of patient, a Heart Failure Group has been created for this catchment area, known as the Muntanya Primary Care Department, which structures the care provided for these patients in seven basic levels that are organised as follows:

• Primary care
• Specialist consultations
• Hospital A&E
• Conventional hospitalisation
• Hospital at home
• Heart Failure Unit
• Centre for Monitoring Chronic Diseases

The Vall d’Hebron Haemodynamics Unit is a centre of excellence with extensive experience in coronary procedures. It has three theatres for operations, one of which is shared with the Arrhythmia Unit. Another one is used for hybrid procedures, with simultaneous participation of specialists in haemodynamics and experts in cardiac surgery. 

The unit has the technology and materials needed to carry out any kind of procedure, such as: 

• rotational angiography 
• optical coherence tomography 
• pressure guides 
• thrombosis capture systems 

The unit is equipped to carry out operations with ventricular assistance and support with extracorporeal membrane oxygenation. It has been working in collaboration with the Pneumology Department for more than 35 years. They combine to treat pulmonary hypertension and to make the assessment before proceeding with lung transplants. The unit is a national benchmark in this field, which is 12% of its total work. It also collaborates with other hospitals internationally. 

The haemodynamics laboratory has advanced anaesthetic and cardiac resuscitation equipment, along with transthoracic, transoesophagal and intracardiac echocardiography. It has specialists working in it for paediatric procedures and for adults with congenital diseases. This guarantees care for patients of any age. 

In 2019, the Haemodynamics Unit carried out: 

• 2,165 diagnostic catheterisations
• 1,360 therapeutic catheterisations. 1,036 of these were angioplasties, of which 304 were angioplasties in the acute phase of a heart attack. 

It was the unit carrying out the most aortic valve implants in Catalonia for the twenty-third consecutive year. Some of these procedures were done using world-leading cutting-edge optimisation techniques. 

Thanks to the collaboration between specialists, more than 190 procedures are carried out on children and more than 80 on adults with congenital heart disease each year. The Cardiology Department takes part in all the structural cardiopathy programmes that need it. It also carries out hybrid procedures in surgery once a month. 

 

Diseases related to this speciality

Acute myocardial infarction and other acute heart diseases
The majority of the procedures in the Haemodynamics Unit relate to ischaemic heart disease. This occurs when cholesterol plaques build up in the coronary arteries. These take the blood to the myocardium, the heart’s muscle tissue that pumps the blood around the blood stream. When the blood flow in the coronary arteries decreases, an ischaemia or acute myocardial infarction occurs. It usually causes a pain similar to pressure on the chest, known as chest angina. When the coronary artery is completely obstructed, an acute myocardial infarction occurs which causes heart cells to die. It is a serious illness and requires the artery to be opened immediately. This is usually done with a catheterisation. The patient is subsequently admitted to the Cardiology Critical Care Unit. 

The Cardiology Department Haemodynamics Unit at Vall d’Hebron treats infarctions with catheterisation 24 hours a day, 365 days a year. It is one of the benchmark hospitals providing continuous care for this illness in Catalonia. 

Heart valve disease
The majority of heart valve diseases can only be treated with cardiac surgery. When the disease is degenerative, due to age and ageing, techniques such as an aortic valve implant or a MitraClip can also be used. To decide on suitable treatment, the “heart team” intervene. This is a multi-disciplinary team, consisting of clinical, surgical, cardiology, imaging and anaesthesia experts and specialists in critical cardiac care. 

Paediatric and adult congenital heart disease
The most frequent heart disease is congenital. Techniques to treat congenital defects via the skin often supplement reconstructive surgery. Vall d’Hebron is a worldwide benchmark for this operation on people of all ages. Paediatric treatments have been developed to adapt to children’s growth and evolution. 

Pulmonary hypertension/lung transplant
Increase in pressure in the pulmonary arteries may be a secondary disorder to other cardiac or pulmonary disease, or also may be a primary problem. The treatment for this disease requires monitoring to control the pressure’s reaction to the drugs. The patient can be monitored using right heart catheterisation and using the vascular/pulmonary remodelling study with intravascular ultrasound. Patients having a lung transplant must undergo a series of cardiac tests beforehand, to ensure the success of the operation. The tests are catheterisation and coronary revascularisation. Catheterisations are also done in a situation of isometric and dynamic physical exercise to assess the heart’s response to the effort. 

 

Treatments and diagnostic tests related to this speciality

The Haemodynamics Unit carries out interventional diagnostic and interventional therapeutic catheterisations.

Interventional diagnostic catheterisations 

The most usual is the study of the heart’s anatomy using a coronary catheterisation. The procedure consists of inserting a catheter into an artery in the forearm or leg until it reaches the coronary artery. The catheter allows the radiocontrast agent to be introduced in order to visualise the artery using radioscopy. Specific material may also be inserted to unblock the artery.

Other diagnostic procedures using a catheter are as follows:

• Haemodynamic and angiocardiogram diagnostics for congenital or acquired heart disease that cannot be diagnosed with other cardiac or cardiovascular explorations
• Pulmonary arterial hypertension study
• Cardiac study prior to a lung transplant
• Endomyocardial biopsy

Interventional therapeutic catheterisations

These are procedures via the skin that enable the treatment of some heart diseases and lesions without surgery.

The most common is coronary angioplasty. This consists of unblocking the coronary artery using a catheter. This is often done in the acute phase of a myocardial infarction, along with suction of the thrombosis that obstructed the artery and caused the infarction. The catheter is also used to insert a stent, a small cylindrical mesh, to completely open the coronary artery at the obstruction point. 

The unit carries out other procedures, such as: 

• Aortic valve implants. This treatment consists of inserting an artificial valve made of biological material via a catheter, to replace the ailing aortic valve. 
• Repair of the mitral valve in cases of insufficiency. A small device is inserted to suture the defective mitral valve and reduce insufficiency. 
• Repair of congenital cardiac defects, such as atrial septal defect or patent ductus arteriosus. There is a particular repair device for each defect. It is inserted using a catheter.
• Pulmonary artery dilations, whether due to congenital narrowing or chronic pulmonary thromboembolisms caused by pulmonary hypertension.

 

Research

The Haemodynamics Unit takes active part in lines of research, for example:

• Myocardial damage, with the aim of using the knowledge for the benefit of the patients.
• The modification of stents, extendible meshes to open arteries, and the arteriosclerosis plaque with a coronary laser 
• The clinical result of closing mitral periprosthetic leaks 
• Early endothelialisation in coronary stents 
• Special coronary stents for bifurcations 
• The repercussion of pulmonary hypertension on the pulmonary arterial wall

 

Education

The Haemodynamics Unit's team of professionals takes active part in academic education and practical training on the medicine and nursing degree courses. Cardiology residents usually spend time at the unit, along with residents from other Spanish, European and Latin American hospitals who are interested in training on this sub-speciality. The unit's professional team regularly takes part in training activities outside the hospital.

Each year, the unit organises a guidance course on treating coronary bifurcations with imaging techniques. It also organises a course on choosing a catheter, as a guide for coronary angioplasty. A course in the form of practical academia on the treatment of chronic occlusions is held twice a year.

 

Experts

The Haemodynamics Unit has a section head and six assistants. They work with the nursing team, which consists of thirteen specialist professionals. The latter work in the theatres and in the hybrid operating theatre, as and when needed.

The Vall d’Hebron Cardiology Department offers specialist care, with advanced procedures and the most innovative technology. It is a pioneer in developing and running clinical-practice protocols. It provides patient-centred service and offers medical care agreed on by the entire Cardiology team. Notable features include its own Clinical Epidemiology Unit and Experimental Cardiology Laboratory. 

The Cardiology Department boasts 37 highly qualified professionals, with specific skills and training.
The team is divided up into the following units: 

• Cardiovascular Critical Care Unit 
• Arrhythmia Unit 
• Cardiac Imaging / Echocardiography, Familial Heart Disease and Aortic Pathology Unit  
• Congenital Heart Disease in Adolescents and Adults
• Haemodynamics and Interventional Cardiology Unit
• Heart Failure Unit

These units are at the forefront of heart-disease treatment and offer multidisciplinary care for patients. The department aims to meet the future challenges of cardiology. A few examples of this are the Familial Heart Disease and Complex Congenital Heart Disease Units. And procedures such as transcatheter valve implanting and treatment for pregnant women with heart disease or endocarditis.

The nursing team is also a key feature for offering excellent care. They take part in every diagnostic and therapeutic procedure, in educating patients, in secondary prevention for the early detection of diseasesand in patient rehabilitation. Their work is especially important for elderly patients with multiple illnesses. Such patients have several programmes at their disposal, including clinical care and cardiac rehabilitation for ischaemic heart disease. The programmes are provided in coordination with the referred area’s primary care and gyms. 

 

Research

The research group in cardiovascular diseases carries out basic, clinical and epidemiological research. Its aim is to generate knowledge for improving prevention and patient diagnoses and treatment.
The group has 19 main researchers and 32 clinical projects and trials currently running. It published 142 papers in 2020.

The research group is part of the CIBERCV network, the Biomedical Research Networking Centre on Cardiovascular Diseases. It collaborates in the following areas: 

• Ischaemia-reperfusion injury: cardioprotection mechanisms, ischaemic conditioning and remodelling. 
• Coronary heart disease: genetic factors involved, determining factors in thrombotic complications and prognosis-factor studies. 
• Aortic diseases: determining factors in aortic dilation, anomalies in aortic biomechanics in Marfan syndrome and new methods for obtaining images. 
• Congenital or familial heart diseases: determining genetic factors and prognosis-factor studies. 

The research group takes part in the CIBERESP, the Biomedical Research Networking Consortium on Epidemiology and Public Health. It focuses on the following aspects:

• studying effectiveness
• cost-effectiveness of cardiovascular operations
• research in health results
• clinical research methods 

  

Education and Training 

The Vall d’Hebron training programme includes:

• undergraduate, master’s and doctoral students from the Autonomous University of Barcelona
• the medical specialisation in Cardiology programme (MIR)
• post-MIR subspecialisation programmes
• ongoing medical education 

The Cardiology MIR programme’s success enables the recruitment of high-level doctors to the hospital. 

The Cardiology Department also includes and jointly supervises an international doctoral school at the University of Barcelona as well as organising important scientific meetings. Vall d’Hebron enjoys international recognition for all the above reasons as well as considerable impact on many areas of knowledge. The department’s professionals collaborate in prestigious international bodies and societies, as well as on the editorial boards of scientific magazines in their field.

Our activity at the Cardiac Surgery Department has been linked to the history of medicine and, more specifically, to the history of cardiac surgery in Catalonia. The Department's development, then, has been made possible thanks to the advances made in cardiac surgery and cardiology in general. Also relevant here is its expansion, from an initial national health system that developed into the current regional health system, regulated by the Catalan Health Service through the Catalan Health Institute.

 The history of our Department dates back to the 1960s, when Dr. Paravisini performed the first surgical operations to repair the mitral valve in the heart, known as "mitral comissurotomies”. The following years saw the beginnings of cardiac surgery using extracorporeal circulation, a technique employed for replacing the heart’s function as a pump and enabling the heart to be stopped and operated on. Surgical operations became standard by the end of the 1970s. It was not until the 80s, however, with the arrival of Dr. Murtra, that there could be said to be a protocol-based programme of operations that produced pioneering results at the time. The number of patients treated has steadily increased: from 400 cases a year using extracorporeal circulation in the 1980s, to 600 at present. 

The current catchment area covers over one million people from the north-eastern part of Catalonia, which includes the counties of Girona and Lleida and the north of the Barcelonès county. This is an extensive geographical area, though its population density is lower than others. We created the Multihospital Care Service to provide care for this area.

Resident cardiovascular surgeons and other specialist doctors working as locums for our Department, jointly take part in pre-operative studies with the Department team, both in surgical indications and in surgical procedures, with a varying degree of involvement, depending on their level of training. These doctors join the Post-Operative Cardiac Surgery Unit (UPCC) immediately after cardiac surgery, provide postoperative care on the ward, and take part in monitoring patients through outpatient consultations.

 

Units making up the Department

• Pacemaker Unit
• Aorta Unit
• Congenital Pathology Unit
• Structural Surgery Unit
• Valvular Surgery

The Arrhythmia Unit works closely with the Critical Cardiology Unit, the Adult Congenital Heart Disease Unit, and the Inpatient and Cardiac Surgery Areas. The Arrhythmia Unit was created in 1975. Since then it has expanded and specialises in various fields.
The most important are as follows: 

• ablations of complex arrhythmias in congenital heart disease in adults
• paediatric ablations
• ventricular tachycardia substrate ablations
• atrial fibrillation ablations

The Arrhythmia Unit has two theatres. One of them is completely dedicated to procedures such as:

• electrophysiological study
• atrial fibrillation ablation 
• supraventricular tachycardia ablation
• focal atrial tachycardia and macro-reentrant atrial tachycardia ablation
• premature ventricular contraction and idiopathic ventricular tachycardia ablation
• ventricular tachycardia ablation in patients with structural heart disease
• atrioventricular node ablation
• heart device implants for diagnosing and treating arrhythmias, such as pacemakers, defibrillators or resynchronisation therapy
• tilt table test
• electrical cardioversion
• drug provocation test 

The unit also has specific clinics to treat and monitor patients with cardiac arrhythmia. These include consultations about devices and five clinics dealing with the following matters: 

• channelopathy and sudden death 
• arrhythmia in congenital heart disease 
• ventricular tachycardia 
• atrial fibrillation

In 2019, the unit carried out:

• 279 ablations, 40% of which were ventricular tachycardia or arrhythmia in congenital heart disease. 
• It also fitted 99 complex intracardiac devices, such as defibrillators and resynchronisation therapy. 

The Arrhythmia Unit works jointly with the Paediatric Cardiology Department on invasive treatment of cardiac arrhythmia in paediatric patients. 

 

Diseases related to this speciality 

People can suffer from slow arrhythmia or fast arrhythmia. This often occurs in hearts affected by a cardiac disease, but also occurs in hearts with a normal structure.

The most common fast arrhythmia is atrial fibrillation, which requires medical treatment and, occasionally, ablation with a catheter. This is a safe procedure and commonly gives good results.

The most common slow arrhythmias are those that appear with age.  They are caused by degeneration of the heart’s electrical system. They usually require a pacemaker to be fitted.

  

Treatments and diagnostic tests related to this speciality

• The electrophysiological study consists of putting a catheter into the heart to analyse the electrical parameters. This is often accompanied by an ablation of the arrhythmia. 
• The ablation consists of applying an energy source to create a lesion in the place where the arrhythmia is generated.
• Fitting a pacemaker enables slow arrhythmias to be controlled. This is done using a device that generates electrical impulses. 
• Fitting a defibrillator enables fast arrhythmias to be detected. This is done using a device that generates an electrical shock so that the heart goes back to beating normally. 
• Cardiac resynchronisation therapy is used in cases of cardiac failure with a loss of power in the heart’s contraction. It consists of fitting special devices that improve the heartbeat and the patient’s quality of life. 

The Arrhythmia Unit also carries out common non-invasive procedures such as:

• 24 hour Holter monitoring. The Holteris a portable, cardiac control device.
• 3 week Holter
• Tilt tests. These tests are done to check the body’s reaction to a change of posture.

 

Research

The Arrhythmia Unit has extensive experience in researching the field of cardiac arrhythmias. It has published many times in specialist journals. The following research lines are highlights:

• Arrhythmia in congenital heart disease
• Loss of consciousness (syncope)
• Intracardiac devices
• Strokes of indeterminate origin, in collaboration with the Neurology Department
• Mechanisms involved in physiological and pathological cardiac remodelling
• Mechanisms involved in atrial fibrillation development
• Effects of air pollution on the development of arrhythmias
• Strategies for improving diagnosis of hereditary illnesses causing sudden death
• Therapies aimed at patients with hereditary illnesses causing sudden death
• Effects of COVID-19 on the development of arrhythmias

 

Education

The Arrhythmia Unit's team of professionals take active part in academic education and practical training on the medicine and nursing degree courses. Cardiology residents usually spend time at the unit, along with residents in other specialities at the hospital. Residents from other hospitals in the Vall d’Hebron area and from other Spanish, European and Latin American hospitals also do so, if they are interested in training on the treatment of arrhythmia diseases. 

The unit's team regularly takes part in training activities outside the hospital. The unit offers the following specific, staff training courses periodically: 

• Cardiac stimulation and implantable systems
• Atrial fibrillation refresher days
• Meeting of experts in arrhythmia in patients with congenital heart disease
• Course on arrhythmia in congenital heart disease

 

Experts

The Arrhythmia Unit has a coordinator and four assistants. They work with the nursing staff, consisting of seven specialist professionals, who deal with caring for patients and doing the invasive electrophysiology treatments. They also monitor patients with intracardiac devices on-site and remotely.