LETTER TO EDITOR
Re. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way? “In God we trust. All others must bring data.” – W. Edwards Deming 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. 206
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.
Syed Murfad Peer, Pranava Sinha Division of Cardiovascular Surgery, Children’s National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010, USA. E‑mail: [email protected]
REFERENCES 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. 2. Iyer KS. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way? Ann Pediatr Cardiol 2013;6:12‑4. 3. STS Congenital Heart Surgery Executive Summary Neonates; 2013. Available from: http://www.sts. org/sts-national‑database/database‑managers/ executive‑summaries. 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. 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. Access this article online Quick Response Code:
Website: www.annalspc.com DOI: 10.4103/0974-2069.115279
Annals of Pediatric Cardiology 2013 Vol 6 Issue 2
Copyright of Annals of Pediatric Cardiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Re. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way? “In God we trust. All others must bring data.” – W. Edwards Deming 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. 206
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.
Syed Murfad Peer, Pranava Sinha Division of Cardiovascular Surgery, Children’s National Medical Center, 111 Michigan Avenue, N.W., Washington, DC 20010, USA. E‑mail: [email protected]
REFERENCES 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. 2. Iyer KS. Treating hypoplastic left heart syndrome in emerging economies: Heading the wrong way? Ann Pediatr Cardiol 2013;6:12‑4. 3. STS Congenital Heart Surgery Executive Summary Neonates; 2013. Available from: http://www.sts. org/sts-national‑database/database‑managers/ executive‑summaries. 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. 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. Access this article online Quick Response Code:
Website: www.annalspc.com DOI: 10.4103/0974-2069.115279
Annals of Pediatric Cardiology 2013 Vol 6 Issue 2
Copyright of Annals of Pediatric Cardiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
