expert commentary

By David Faraoni, MD, PhD
Boston Children’s Hospital
Boston, MA

This article written by Dr. Biajal perfectly summarizes current evidence regarding the risk associated with non-cardiac surgery and invasive procedures performed in children with congenital heart disease (CHD). Different studies have reported an increased incidence of perioperative mortality and complications in children with CHD undergoing non-cardiac surgery. However, as nicely pointed out by Dr. Biajal, the ability to stratify differences in the risk of adverse outcomes among children with major and severe CHD has never been studied.

Risk stratification is crucial for daily clinical decision-making, and for the development of multidisciplinary strategies aimed at allocating perioperative material (e.g. diagnostics and monitoring) and human (e.g. cardiac vs. pediatric anesthesiologist) resources. Based on the available literature, we know that children with single ventricle physiology are at increased risk for perioperative complications. In addition, children with uncorrected CHD, children with documented pulmonary hypertension, those with ventricular dysfunction requiring chronic medications, those listed for heart transplant (Severe CHD), and those with significant post-correction residual lesion (Major CHD) should be considered at higher risk for perioperative complications when compared to children with a repaired CHD without residual hemodynamic abnormality (Minor CHD).

Last but not least, markers of critical illness (e.g. inotropic support, mechanical ventilation, acute kidney injury) identified at the time of the non-cardiac surgery may also be taken into account.

To date, no risk stratification tool has been specifically designed to assess the risk in children with major and severe CHD undergoing non-cardiac surgery. In a study performed by our group (together with Drs. Vo, Nasr, and DiNardo), we were able to identify eight predictors for in-hospital mortality in children with major and severe CHD undergoing non-cardiac surgery, and developed a risk stratification score that could be used to predict in-hospital mortality in this high risk population (manuscript currently undergoing final review).

Considering the improvement made in term of diagnosis and management of children with CHD, an increasing number of children with CHD are requiring non-cardiac surgery or invasive procedures. Consequently, further efforts are urgently needed to improve preoperative risk stratification, to identify the optimal environment for surgical procedures, to build multidisciplinary teams trained to care for children with CHD, and define management strategies for improving outcomes in this high-risk population.