Fetal Heart Surgery - Economics

Dateline: 03/10/98

With the explosion of technology in cardiac surgery, it is difficult to point to one development and say "This is it, THIS is the most innovative advance in recent times". Over the past month, we have discussed the concept of minimally invasive heart surgery, and the use of this novel technique in treating coronary artery disease , heart valve disease and birth defects of the heart. For more information on minimally invasive surgery, visit the MICAS website. However, the concept of treating diseases of the heart even when the "child" is in the womb - fetal intervention - is perhaps the nearest to "IT".

Fetal Heart Surgery is an idea which has totally captured my imagination. It is at once bold and daring, exciting and scary. Is nothing sacred, forbidden, inaccessible any longer - even the fetus in its protective shell ? Not everyone, though, is as enthusiastic about it. Fetal surgery has strong detractors as well. So I thought of starting a forum to discuss this contentious issue.

What was merely a "fanciful figment of a fevered fanatic's fantasy" just a decade ago is now `frighteningly' near becoming reality. It is only a matter of time - and not much time too - before human fetal open-heart operations will be feasible with a fair chance of success. Many, many issues now become pertinent. I will discuss some of these here. It would be nice if you could suggest others as well.

This week, the issue is ....

WHAT PRICE FETAL SURGERY ?

Today's world is cost conscious - sometimes maybe even "cost - obsessed" ! It is however only appropriate that such an esoteric thing as fetal heart surgery be critically evaluated from the standpoint of the economics involved.

Until today, only animal research has been done in fetal heart-lung bypass. Sheep models have been used, because some fetal physiologic data is already available on sheep that may be comparable to human fetuses. Also the sheep fetal size is almost the same as a human fetus.

However, this research is not cheap. Specially designed equipment, suitable for the extremely small sizes (the entire heart may only be a few centimeters in size) doesn't come cheap. The costs involved in the intensive monitoring before and after surgery, and analyses of results, is also high, if not astronomical.

The next step is to extend the experiments to non-human primates. This is likely to escalate the costs. One pregnant rhesus monkey alone costs about 3500 US Dollars !

And when this succeeds, the next giant leap will be to human fetal intervention. Here, the "economy-indicator" will perhaps go haywire, since there can be no longer any room for errors. Many safety checks will have to be added, and the overall expense may well be prohibitive.

The expense is one of the main reasons that fetal surgical research even today remains restricted to just a handful of centers all over the world.

But there's the other side of the coin. Cardiac surgery has always been an expensive proposition. For the cost of a single complex Fontan operation, all of Mexico could be immunized against polio.

The pay-off of course comes in costs saved in reconstructive surgery after birth. Consider the example of a heart anomaly detected in the fetus, left alone and delivered at term. This infant would now require intensive care, and then surgery (probably staged multiple operations), each with its chances of post-operative complications. Inevitably, some will fail conventional treatment, and may require transplantation. And the cumulative costs of these procedures will be equally high.

So are we being caught between a rock and a hard place ? Researchers of fetal cardiac surgery ardently believe that in-utero intervention will reduce, or even (wishfully) abolish, need for any future procedures. Thus, whatever is spent on researching this concept would be an investment in the future.

I too am inclined to agree with this idea, and hope I am proved right. But again, all of this is speculation without support by hard facts.

Next week : Survival After Fetal Heart Surgery.