Annals of Pediatric Cardiology
About us | Current Issue | Archives | Ahead of Print | Instructions | Submission | Subscribe | Advertise | Contact | Login 
     
     
 


 

 
     
    Advanced search
 

 
 
     
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References

 Article Access Statistics
    Viewed1421    
    Printed33    
    Emailed0    
    PDF Downloaded113    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents   
LETTER TO EDITOR  
Year : 2013  |  Volume : 6  |  Issue : 2  |  Page : 206
Re. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way?


Division of Cardiovascular Surgery, Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010, USA

Click here for correspondence address and email

Date of Web Publication20-Jul-2013
 

How to cite this article:
Peer SM, Sinha P. Re. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way?. Ann Pediatr Card 2013;6:206

How to cite this URL:
Peer SM, Sinha P. Re. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way?. Ann Pediatr Card [serial online] 2013 [cited 2019 Dec 9];6:206. Available from: http://www.annalspc.com/text.asp?2013/6/2/206/115279


Sir,

We read with interest the report by Balachandran et al., titled 'Stage one Norwood procedure in an emerging economy: Initial experience in a single center'. [1] The authors deserve to be congratulated for leading the frontier in the palliation of Hypoplastic Left Heart Syndrome (HLHS) in India.

The invited comment [2] is also insightful to the daily challenges any clinician in the non-western world faces, in trying to provide optimal care to his/her patients, while still balancing resource utilization in a limited infrastructure. However with changing economic times and the global stature of India, especially in the field of medicine, and in the environment of growing medical tourism, it is time to pause and reconsider our personal experiences and prejudices and more importantly the published data, before making medical decisions.

While the Norwood stage 1 procedure is among the high-risk procedures, it does not stand there alone. A review of the Society of Thoracic Surgeons - Congenital Heart Surgery Executive Summary for Neonates, [3] will reveal that there are many other commonly performed and less talked and debated about procedures that have high operative mortality. Therefore, denying one procedure while continuing to offer the others is not justifiable based on outcomes alone.

Also the notion that high-risk biventricular repairs like the double switch are 'more gratifying' is ill conceived, as arguably a re-intervention rate of 50% and a 10-year survival of approximately 80% that this procedure offers is arguably no better than a single ventricle patient palliated along the Fontan pathway, [4] HLHS included.

There are innumerable other diseases and procedures across, not just congenital cardiac surgery, but the entire surgical specialty and subspecialties, which are readily offered and often aggressively promoted, despite the outcome data being no better than the Norwood procedure.

While on the one hand we are willing to revive the antiquated ethical debate regarding the optimal management of HLHS in the neonatal period (Norwood Stage 1 palliation vs. no intervention) citing poor outcomes and poor cost benefit ratio, we completely ignore similar or worse lesions that we readily operate upon, which are equally burdensome to our medical infrastructure.

The cost of healthcare can be reduced by indigenization, innovation, training of manpower, and teamwork. [5] It may be judicious to select the appropriate risk-stratified patients, and exclude cases with high-risk factors like intact interatrial septum/obstructed pulmonary venour return, diminutive ascending aorta, premature and low birth weight infants with genetic syndrome, and late referrals.

In the ideal world no patient would be denied care due to lack of resources. If we do have to ration healthcare in the name of cost benefit ratio, it should be data driven, and more importantly, be inclusive of the full spectrum of congenital heart disease rather than exclusively for hypoplastic left heart syndrome.

 
   References Top

1.Balachandran R, Nair SG, Gopalraj SS, Vaidyanathan B, Kottayil BP, Kumar RK. Stage one Norwood procedure in an emerging economy: Initial experience in a single center. Ann Pediatr Cardiol 2013;6:6-11.  Back to cited text no. 1
    
2.Iyer KS. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way? Ann Pediatr Cardiol 2013;6:12-4.  Back to cited text no. 2
    
3.STS Congenital Heart Surgery Executive Summary Neonates; 2013. Available from: http://www.sts.org/sts-national-database/database-managers/executive-summaries.  Back to cited text no. 3
    
4.Murtuza B, Barron DJ, Stumper O, Stickley J, Eaton D, Jones TJ, et al. Anatomic repair for congenitally corrected transposition of the great arteries: A single-institution 19-year experience. J Thorac Cardiovasc Surg 2011;142:1348-57. e1.  Back to cited text no. 4
    
5.Talwar S, Choudhary SK, Airan B, Juneja R, Kothari SS, Saxena A, et al. Reducing the costs of surgical correction of congenitally malformed hearts in developing countries. Cardiol Young 2008;18:363-71.  Back to cited text no. 5
    

Top
Correspondence Address:
Pranava Sinha
Division of Cardiovascular Surgery, Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2069.115279

Rights and Permissions




 

Top