Intraoperative Cardiac Events in Pediatric Patients with Congenital Heart Disease Undergoing Noncardiac Procedures: Analysis of a Large Multicenter Registry

BACKGROUND: Patients with congenital heart disease (CHD) remain at high risk for morbidity and mortality when undergoing noncardiac procedures. Existing studies have utilized national databases focusing on mortality or are limited by small data sets from single institutions. Through a multi-institutional registry study, the primary aim was to describe the incidence of intraoperative cardiac events in patients with CHD undergoing noncardiac procedures. The secondary aim was to describe the risk factors associated with the events. METHODS: Patients with CHD from birth to 21 yr undergoing noncardiac procedures between January and December 2021 were identified at all participating centers. The primary outcome was occurrence of an intraoperative cardiac event at each encounter, defined as the composite of intraoperative hemodynamic instability, cardiac arrest, and pulmonary hypertensive crisis. RESULTS: The final analysis involved 4,343 unique patients at 7 centers undergoing 6,455 procedures. Among the cohort, 335 of 6,455 procedures involved an intraoperative cardiac event (5.2%) in 296 unique patients. The most common event was hypotension (n = 315, 4.9%); there were 12 occurrences of cardiac arrest (0.2%). Univariate analysis showed multiple factors associated with an increased likelihood of intraoperative cardiac events including patient and procedure characteristics, cardiac disease severity, and anesthetic management. Examples of patient characteristics included prematurity (odds ratio, 1.34; 95% CI, 1.02 to 1.76; P = 0.038); gastrointestinal (odds ratio, 1.51; 95% CI, 1.15 to 1.99; P = 0.003) or respiratory (odds ratio, 2.12; 95% CI, 1.62 to 2.76; P < 0.001) chronic medical conditions; preoperative ventilatory support (odds ratio, 3.88; 95% CI, 2.8 to 5.38; P < 0.001); concurrent respiratory illness (odds ratio, 2.18; 95% CI, 1.47 to 3.2; P < 0.001); major CHD (odds ratio, 2.09; 95% CI, 1.54 to 2.83; P < 0.001); and severe CHD (odds ratio, 3.48; 95% CI, 2.47 to 4.91; P < 0.001). CONCLUSIONS: Pediatric patients with severe CHD, those undergoing emergency procedures, and those undergoing surgical interventions were at higher risk of not only mortality as shown previously but also hemodynamic instability. These are established risk factors for intraoperative cardiac events and should be considered when planning risk mitigation strategies.