SURVIVAL AFTER FETAL SURGERY

In fetal surgery, a peculiar situation exists. Each intervention would have TWO SURVIVALS !

The first survival would be after the fetal operation is performed, and the fetus replaced within the protective womb. Heart action would have to recover enough to sustain life through the rest of the gestational period.

The second survival would be the REAL one, when the fetus reaches viability and is delivered at or near term. At this time, in every sense - legal, medical and ethical - the child could be called a "survivor" !

Its "early days" yet, and we have absolutely no evidence to say what kind of survival can be expected after fetal surgical interventions. This is why, atleast to begin with, fetal surgery can only be recommended for those extremely sick fetuses, with complex malformations which anyway have a high attrition rate when untreated.

Most investigators in the field firmly believe that the concept of in-utero correction has the potential to salvage a significant proportion of fetuses which would otherwise NOT make it through pregnancy. Indeed, that is the only justification of developing such a complex procedure.

I have some reservations over this issue. Granted that these infants do survive to term and are delivered from the womb, what evidence is there to predict how they will behave after this ? Survival also means how long they will live, and with what quality of life. My concerns are in two areas.

First, we are intervening in a "genetically weak" subset of fetuses. Many more undetectable anomalies involving other systems may coexist, which in their own right will reduce survival. Correcting the "fatal" heart defect will "unmask" them. We may then end up with poor long term survival from non-cardiac causes.

Second, what about complications introduced by the procedure itself ? Neurologic complications - involving the brain and nerves - are particularly tragic. Would it be justified to deliver a infant with a repaired heart, but accept a damaged brain as the price of this ? I would guess not.

And third, what if these complications are not fatal, but proved disabling nonetheless ? We would then be faced with a population of "walking wounded".

Who should make decisions about the level of intensive care to be extended to these unfortunate survivors ?

Many issues thus remain to be thrashed out in the experimental lab, as well as in medical, surgical, ethical and religious fora regarding similar issues. Its time the concerned bodies take cognizance of the impending arrival of fetal cardiac surgery on the clinical scene, and prepare themselves in all ways.

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