Authors: Nasr V.G. et al.
Anesthesiology, October 3, 2025. DOI: 10.1097/ALN.0000000000005783
This large multicenter registry analysis provides one of the most comprehensive assessments to date of intraoperative cardiac events in pediatric patients with congenital heart disease (CHD) undergoing noncardiac procedures. Prior research on this high-risk group has been limited by either national datasets lacking clinical detail or small single-institution studies.
Data were collected from seven tertiary pediatric centers for all patients with CHD (birth to 21 years) who underwent noncardiac procedures in 2021. The primary outcome was the occurrence of an intraoperative cardiac event—defined as hemodynamic instability, cardiac arrest, or pulmonary hypertensive crisis—recorded for each encounter.
Among 4,343 unique patients undergoing 6,455 procedures, intraoperative cardiac events occurred in 335 procedures (5.2%), involving 296 patients. The most common event was hypotension (4.9%), followed by cardiac arrest (0.2%). Several risk factors were strongly associated with event occurrence:
-
Prematurity (OR 1.34, 95% CI 1.02–1.76)
-
Chronic gastrointestinal or respiratory disease (OR 1.51 and 2.12, respectively)
-
Preoperative ventilatory support (OR 3.88)
-
Concurrent respiratory illness (OR 2.18)
-
Major or severe CHD (OR 2.09 and 3.48, respectively)
Children undergoing emergency or surgical (as opposed to diagnostic) procedures were also at increased risk.
These findings underscore that while mortality among CHD patients has improved, intraoperative hemodynamic instability remains a frequent and clinically significant concern. The data highlight the importance of preoperative risk stratification, optimization of comorbidities, and meticulous anesthetic planning—especially in those with severe or cyanotic disease.
What You Should Know
-
Intraoperative cardiac events occurred in about 1 in 20 procedures among pediatric CHD patients undergoing noncardiac surgery.
-
Hypotension was the most common event; cardiac arrest was rare.
-
Key risk factors included prematurity, chronic illness, ventilatory dependence, active respiratory infection, and severe cardiac disease.
-
Careful preoperative optimization and tailored anesthetic management are essential to reduce intraoperative instability in this vulnerable population.
Thank you to Anesthesiology for publishing this important multicenter study clarifying the incidence and predictors of intraoperative cardiac events in children with congenital heart disease.