Authors: Nasr VG et al.
Journal: Anesthesiology, December 9, 2025. DOI: 10.1097/ALN.0000000000005783
Summary
This large multicenter registry study evaluated the incidence and risk factors for intraoperative cardiac events in pediatric patients with congenital heart disease (CHD) undergoing noncardiac procedures. Unlike prior studies limited to mortality outcomes or single-center experiences, this analysis provides granular, contemporary data on intraoperative hemodynamic instability in a high-risk pediatric population.
Investigators analyzed 6,455 noncardiac procedures performed in 4,343 children with CHD across seven institutions over a one-year period. Intraoperative cardiac events—defined as a composite of hemodynamic instability, cardiac arrest, or pulmonary hypertensive crisis—occurred in 5.2% of procedures, affecting 296 unique patients. Hypotension accounted for the vast majority of events, while cardiac arrest was rare but clinically significant.
Multiple patient-, disease-, and procedure-related factors were associated with increased event risk. Prematurity, gastrointestinal and respiratory comorbidities, preoperative ventilatory support, and active respiratory illness markedly increased vulnerability. Cardiac disease severity demonstrated a strong dose–response relationship, with major and severe CHD conferring substantially higher risk. Emergency procedures and surgical interventions further amplified event likelihood.
The findings underscore that perioperative risk in pediatric CHD extends beyond mortality and includes frequent intraoperative instability. These results reinforce the importance of detailed preoperative risk stratification, multidisciplinary planning, and proactive hemodynamic management strategies for children with complex CHD undergoing noncardiac anesthesia.
Key Points
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Intraoperative cardiac events occurred in 5.2% of noncardiac procedures in children with CHD.
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Hypotension was the most common event; cardiac arrest was uncommon but present.
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Severity of congenital heart disease strongly increased intraoperative risk.
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Respiratory comorbidities, prematurity, and preoperative ventilatory support were key risk factors.
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Emergency and surgical procedures further elevated risk.
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Findings highlight the need for targeted perioperative risk mitigation beyond mortality-focused outcomes.
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