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

This Unit is located on the sixth floor of the General Hospital, and currently has eleven haemodialysis stations, with five points in the Positive Unit and six points in the Negative Unit, to offer dialysis for patients with Chronic Kidney Disease (CKD) on haemodialysis (HD) with an ultrapure water plant with double reverse osmosis.

Plans are in place for a redesign of the floor where the Dialysis Unit is located, with 14 haemodialysis stations with beds for chronic patients (approx. 40 patients). This will mean we can admit more patients while offering 2 haemodialysis points for patients with hepatitis B virus.

Portfolio of services 

• Haemodialysis of patients with chronic kidney disease.
• High-flow haemodialysis.
• Haemofiltration with endogenous reinfusion.
• On-line haemodiafiltration.
• Treatment for acute kidney failure in the patients mentioned above.
• Intermittent haemodialysis.
• Continuous veno-venous haemodiafiltration techniques
• Treatment of acute renal failure from the various Critical Units; ICU (General Hospital), ICU (Hospital of Traumatology) Resuscitation, Serious Burns, Postoperative Cardiac Surgery Unit and Coronary Unit.
• Peritoneal dialysis. Teledialysis, which allows the monitoring of patients or dysfunctions without requiring their physical presence.
• Plasmapheresis in patients with immunological diseases and rejection using antibodies.
• Leukocytapheresis and patients with chronic inflammatory bowel disease, where indicated (agreed with the Digestive System Department).
• Continuous ultrafiltration of patients with congestive heart failure resistant to treatment with conventional medication (agreed with the Cardiology Department).
• Periodic monitoring of the vascular access using Doppler ultrasound techniques and other non-invasive flow measurement techniques.
• Joint outpatient consultation for Nephrology and Vascular Surgery to assess new vascular accesses or dysfunctional vascular accesses.
• Collaboration with Interventional Angioradiology for rapid diagnosis and treatment of acute vascular access dysfunction.
• Relationships with peripheral haemodialysis centres, of which the Dialysis Unit at Vall d'Hebron University Hospital is a centre of reference.
• Patients are visited once a year by doctors from the Unit.
• Twice-yearly meetings with the medical offices of the dialysis centres, of which we are a reference centre.
• Joint dialysis quality protocols covering: anaemia, osseo-mineral metabolism, dialysis dosage, nutrition, vascular accesses according to the SEN guidelines and Strategic Plan for the Management of Nephrological Patient Care.
• Updates and optimisation of the list of patients on the waiting list for transplant.

We give nutritional and diet support to hospitalised patients across all clinical departments at the Hospital, and carry out follow-up monitoring at outpatient care for those patients who need it. We also provide outpatient care for patients referred from other healthcare areas of the Hospital and primary care centres that require specialist nutritional and dietary support. Patients requiring nutritional support are treated at the Horta Primary Care Centre. We actively collaborate in educational programmes to detect nutritional problems and for home monitoring of enteral nutrition, that is, feeding via a tube.

As a transversal unit, we support the General, Maternity and Children’s and Traumatology, Rehabilitation and Burns Hospitals, as well as the Primary Care Office in Sant Andreu; we also collaborate with a range of different medical and surgical specialties. We also participate in and direct a number of joint protocols with various other areas of the Hospital, and we maintain a very close working relationship with the Pharmacy Department, both in developing artificial nutrition and in selecting nutritional products. We act together with the Biochemistry Department in monitoring the nutrition of patients and in pursuing lines of research. We also provide support for the Pere Virgili Health Park.

We work to educate patients and family members, as well as providing courses for our staff through our continuing education programme, and we collaborate on continuing education in primary care. We organise training courses for primary care nursing staff, nursing staff from the Hospital and our orderly staff. We also educate patients and relatives about managing enteral nutrition, parenteral nutrition, as well as nutrition in cases of nephrology and inflammatory bowel disease.

Portfolio of services 

During a hospital stay, the nutrition support we provide might cover:

• Diet: adapted and/or personalised diet. In some cases where a conventional diet is not able to meet the needs of patients, nutritional supplements are prescribed.
• Artificial nutrition (enteral or parenteral) according to protocol. Prescription, preparation and monitoring of efficacy and safety of the treatment.

Once a patient has been discharged, we continue to monitor nutritional treatment through:

• Home nutrition programmes (enteral and parenteral)
• Nutritional evaluation and support through consultations
• Daily consultations with a nutritionist
• Preparation of diets after discharge for different diseases

In short, we prepare diets for hospital patients, always taking into account menu alternatives, menus for treatment and diet changes depending on patient cycles. We work together with the Catering Unit to organise and prepare the hospital’s catering operation.

Finally, we also take care of preparing and distributing baby bottles, baby food and special liquid meals for healthcare units, as well as collecting and cleaning utensils.

Teaching

Our teaching work includes:

• Training undergraduate doctors and specialists in endocrinology and nutrition in accordance with the medical residency programme
• Undergraduate training in diet and human nutrition (University of Vic, University of Navarre, University of Barcelona, Blanquerna University, Polytechnic University of Valencia, University of Zaragoza)
• Degree in Dietetics and Human Nutrition (University of Barcelona, Blanquerna University)
• ERASMUS exchange programme for dietitians (Portugal, Mexico, Italy)
• Extended visits for dietitians from abroad (Argentina, Mexico)
• Postgraduate training: Master's degree in nutrition from the Autonomous University of Barcelona (Autonomous University of Barcelona, University of the Balearic Islands, University of Granada)
• Periodic clinical sessions: reviews and clinical cases

Portfolio of services

Our Department comprises various different units each with their specialities.

Prostate Pathology Unit

• Early diagnosis of prostate cancer
• Prostate biopsy laboratory
• Multidisciplinary surgical prostate cancer treatment
• HBPUrinary dysfunction and diagnosis of benign prostatic hyperplasia (BPH)
• Surgery and minimally invasive treatment of benign prostatic hyperplasia

Renal Pathology, Retroperineal and Kidney Transplant Unit

• Diagnosis of kidney tumours
• Surgical and multidisciplinary treatment of kidney tumours
• Diagnosis and treatment of pyeloureteral stenosis
• Kidney transplant programme

Urothelial Tumours Unit

• Diagnosis of bladder tumours and urothelial tumours
• Endoscopy laboratory
• Surgical and multidisciplinary treatment of urothelial tumours
• Endovesical Oncology Treatment Laboratory

Lithiasis Unit

• Diagnosis of urinary lithiasis
• Multidisciplinary treatment of urinary lithiasis

Andrology Unit

• Diagnosis and multidisciplinary treatment of erectile dysfunction
• Male infertility
• Diagnosis and treatment of urethra stenosis
• Endourethral treatment laboratory

Functional Vesicular Pathology and Neurourology

• Diagnosis of bladder dysfunction and urinary incontinence
• Multidisciplinary treatment of bladder dysfunctions and urinary incontinence
• Urodynamics laboratory and videoeurodynamics
• Endovesical treatment laboratory
• Diagnosis and treatment of urological pathology in spinal cord injuries
• Diagnosis and treatment of urological pathology in multiple sclerosis

Research 

Over the last fifteen years, we have put significant efforts into translational research in order to apply knowledge gained from basic research to the prevention and treatment of clinical cases, within the framework of the Vall d'Hebron Research Institute (VHIR). This is why we have several research programmes of recognised international prestige. The result of this commitment to research is the transfer of knowledge in the form of publications and patents.

Teaching

At the Urology Department, we are committed to training graduates and postgraduates from the Faculty of Medicine of the Autonomous University of Barcelona, as well as training medical residents to be specialists in our field. Since 1973, we have trained more than sixty specialists, distributed throughout Spain and other countries.

In addition to treating patients with liver diseases, the Hepatology Service also collaborates intensively in the liver transplant program together with the Hepatobiliary and Pancreatic Surgery and the Digestive System Transplant Services. Moreover, we collaborate with the Gastrointestinal Unit of the Digestive System Service in taking care of hepatic patients with gastrointestinal bleeding, and in the control of haemophilic patients from the Haemophilic Unit.

Portfolio of services 

• Care for admitted patients
• Outpatient care
• Hepatology interconsultations
• Internal medicine interconsultations
• Primary care consultations
• Liver biopsies
• Fibroscan  
• Psychometric tests
• Paracentesis
• Clinical trials in hepatology

Research 

The Hepatology Department is part of the Vall d'Hebron Research Institute (VHIR) with its own research group, the Hepatic Diseases Group. We are involved in clinical, basic and experimental research in liver diseases.

Teaching

We also carry out significant teaching activity, with members of the Department involved in teaching medical residents (tutorials); medical degree teaching from fourth to sixth year; postgraduate teaching (doctoral theses) after the residency, as well as providing research fellowships and continuing education.

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.

In our Department, we treat diseases such as diabetes, morbid or grave obesity and disorders derived from the thyroid gland and the pituitary gland.

We have a Day Hospital where we attend to patients with chronic illnesses that until now required hospital admission, but for which patients can now be treated as outpatients. This is the case, for example, of diabetic patients with acute decompensations. We also have a unit specialising in Diabetic Foot.

The Day Hospital offers primary care, improving coordination between the hospital and primary care centres. Every month, we attend to about 300 patients, most of whom are diabetic patients with uncomplicated acute illnesses. We carry out about 20 tests every month, and we also carry out telephone monitoring of patients when we have to monitor certain types of treatments.

The Day Hospital also performs functional tests to determine the patient's condition. One example is the implantation of insulin perfusion pumps, a device the size of a mobile phone that administers insulin 24 hours a day through a cannula that is implanted under the skin of the patient with type 1 diabetes. We also use devices to constantly monitor glucose levels. The devices are minimally invasive and designed to measure glucose levels and provide information on any fluctuations.

At the Endocrinology and Nutrition Department and the Nutrition Support Unit, we regularly organise information courses aimed at diabetics and their families, with the aim of improving their quality of life. These courses cover how to control diabetes, avoid decompensations and prevent chronic complications.

Diabetic Foot Unit

At the Diabetic Foot Unit, we treat the range of syndromes that affect the feet of patients with diabetes. The possible complications of type 2 diabetes mellitus, which affects 6.5% of the population between 30 and 65 years old, according to data from the Department of Health, include neuropathy, where the nerves of the feet are affected, ischemia, which causes a progressive decrease in blood flow to the foot, and infection. These complications cause tissue damage to the skin, or foot ulcers, causing significant morbidity and sometimes leading to amputation.

We have a multidisciplinary team that was set up to ensure early detection of any complications due to the disease and thus avoid the need for amputations. This involves the following departments: Traumatology and Orthopaedic Surgery, Physical Medicine and Rehabilitation, Infectious Diseases, and Angiology and Vascular and Endovascular Surgery.

We focus on treating the functional, structural and neoplastic pathology of the upper digestive tract.

Portfolio of services 

We are specialists in the following surgical techniques:

Benign oesophageal pathology surgery

• Oesophageal perforations
• Oesophageal stenosis (caustic, peptic, etc.)
• Achalasia
• GERD
• Hiatal hernia
• Oesophageal diverticula
• Benign oesophageal tumours (lymphomas)

Malignant oesophageal pathology surgery

• Cancer of the oesophagus

Benign gastric pathology surgery

• Pathology of gastrointestinal ulcer complications

Malignant gastric pathology surgery

• Gastric cancer
• Gastrointestinal stromal tumours (GIST)
• Oesophagogastric neuroendocrine tumours

Diaphragm pathology surgery

• Morgagni hernias
• Traumatic diaphragmatic hernias
• Hiatal hernias

We offer excellence in care for thyroid surgery, and our clinical research and the use of the latest techniques, such as recurrent nerve monitoring and visual amplification of the surgical field, mean the care provided for this pathology guarantees the highest standards, both in benign and malignant pathology.

As for parathyroid pathology, we always try to use minimally invasive techniques.

Adrenal pathology is addressed primarily through laparoscopic surgery, and the Unit has acquired extensive experience over the years.

In the fields of bariatrics and metabolism, we perform all types of technique, both restrictive and malabsorptive and mixed techniques: gold standard, laparoscopic gastric bypass and vertical laparoscopy.

Portfolio of services

The introduction of robotic surgery at the Unit means we have become pioneers in robotic bariatric surgery, with the creation of a model of robotic surgical technique for gastric bypass and tubular gastroplasty.

Surgery is a fundamental pillar for patients diagnosed with morbid obesity living with health problems such as diabetes mellitus, hypertension, cardiocirculatory problems and respiratory disorders. The objective of bariatric surgery is twofold: on the one hand, to re-educate eating habits so that the maximum loss of excess weight can be achieved in the shortest amount of time possible in a sustainable way and, on the other hand, to prevent, reduce and treat obesity-related comorbidity.

Our arsenal of surgical techniques, such as gastric bypass and vertical gastrectomy, includes more complex techniques to alleviate the devastating effects of obesity on such patients. Likewise, in the last 15 years, developments in robotic surgery (where the surgeon operates on the patient through the use of a robot that responds to their orders, improving precision, vision and possibilities of movement) mean these techniques can be carried out more safely and have become more commonplace.

Vall d'Hebron University Hospital is a European reference centre in robotic surgery for obesity. In 2012, we were the first hospital in Spain to operate on the first adolescent patients with morbid obesity, and we are currently recognised as a centre of European excellence.

The joint work of bariatric surgeons and endocrinologists means the Unit is in a privileged position when it comes to metabolic surgery to treat diabetes, when appropriate.

Research 

The Section carries out its own research projects, collaborating with other hospitals and other Departments within our Hospital, further information about which can be found in the publications and research sections.

Teaching

For teaching, our Section has two resident doctors who rotate periodically. We also train medical students from the Autonomous University of Barcelona in the surgical disciplines related to our Unit.