Outcomes After Noncardiac Surgery in Children With Heart Disease
What are the incidence of mortality and major adverse postoperative outcomes following noncardiac surgery in children with congenital heart disease (CHD), as compared with the general population?
Data from the 2012 pediatric database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were reviewed. After propensity score matching and stratification by severity of CHD, mortality and adverse postoperative outcomes were compared between controls and children with CHD. Minor CHD included atrial septal defect, small to moderate ventricular septal defect, or repaired defects without significant residua. Major CHD included repaired defects with significant residua and palliated single-ventricle lesions. Severe CHD included uncorrected cyanotic disease, pulmonary hypertension, ventricular dysfunction requiring medications, or those awaiting heart transplant.
Of a total of 51,008 children enrolled in the database, 4,520 children with CHD undergoing noncardiac surgery were identified. After propensity score matching, 2,805 children with minor CHD, 1,272 with major CHD, and 417 with severe CHD were included. The incidence of overall mortality was significantly higher in children with moderate (3.9% vs. 1.7% in controls, p < 0.001) and severe (8.2% vs. 1.2% in controls, p = 0.001) CHD. For patients with severe CHD, both 30-day (odds ratio [OR], 8.43; 95% confidence interval [CI], 2.52-28.21) and overall mortality (OR, 7.32; 95% CI, 1.37-3.79) were increased, as compared with controls. For children with major disease, overall mortality (OR, 2.28; 95% CI, 1.37-3.79), but not 30-day mortality was increased, as compared with controls. No difference was seen between children with minor disease and their matched controls.
The authors concluded that children with major and severe CHD undergoing noncardiac surgery have an increased risk of mortality compared to children without CHD.
The most telling aspect of this study is the very high mortality rates seen in patients with major and severe CHD around the time of noncardiac surgery. For the overall mortality analysis, it is difficult to be sure of causality, as the very high risk patients have a certain constant mortality risk. However, the high 30-day mortality rates of 3.9% in the major CHD and 8.2% in the severe CHD groups are almost certainly related to the procedure. These data should be considered in the risk-benefit analysis of children with CHD undergoing noncardiac surgery, particularly elective procedures. Further study will be necessary to determine whether this risk may be mitigated by the use of specialized cardiac anesthesiology teams and availability of specialized cardiac intensive care in the perioperative period.
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