Transcatheter versus surgical closure of CHDs in predominantly pediatric populations: a systematic review of comparative and single-arm evidence

BACKGROUND: Transcatheter closure increasingly replaces surgery for congenital heart defects (CHDs), but comparative evidence comes almost entirely from atrial septal defect. We asked whether its trade-offs hold for other lesions in predominantly pediatric cohorts. METHODS: We searched PubMed, Embase, and Cochrane CENTRAL to June 2026 for cohorts with mean or median age under 18 years (PRISMA 2020). Only direct comparisons informed comparative conclusions. Narrative synthesis was stratified by lesion, with sensitivity analyses for mixed-age cohorts and adverse-event definitions. RESULTS: Six of eleven studies compared both approaches (1,158 transcatheter, 490 surgical patients), in atrial septal defect, patent ductus arteriosus, and coronary artery fistula; none addressed muscular ventricular septal defect. Procedural success was high with both. Hospital stay was shorter after transcatheter closure in all six (2.4-4.4 days in atrial septal defect), the most consistently observed finding. Major adverse events were less frequent after transcatheter closure in atrial septal defect, but arms differed in age and weight, and the difference was inconsistent in wholly pediatric cohorts; in coronary artery fistula, one study at serious risk of bias found them over twice as frequent after transcatheter closure. Where both arms were followed, reintervention was uncommon in each. GRADE certainty was low for hospital stay and procedural success, otherwise very low. CONCLUSIONS: Shorter hospital stay after transcatheter closure is the most consistently observed finding, at low certainty. Neither approach is shown to be safer: safety findings differed between lesions and, beyond atrial septal defect, rest on single studies. Lesion anatomy determines which approach applies.