Surgical Timing and Physiology-Specific Outcomes in Congenital Heart Disease

BACKGROUND: In low- and middle-income countries, most children with congenital heart disease reach the operating room after the guideline-recommended window has closed. Existing analyses grade delay by chronological age or a binary early/late split and report outcomes in aggregate, not by physiology. METHODS: All 12,190 consecutive pediatric congenital heart operations at a single Indian tertiary center (2020-2025) were graded against national guidelines using a lesion-normalized Guideline Deviation Score, from G0 (timely) to G4 (critically delayed). Logistic regression and restricted cubic splines assessed operative mortality, morbidity, and resource utilization overall and within seven pre-specified physiological subgroups. RESULTS: Of 10,187 gradable operations, 73.7% were delayed and 34.8% critically delayed. Operative mortality was 2.1% (adjusted OR per grade, 0.88 [95% CI, 0.81-0.96]; P = .004). Fontan-stage palliation was the only subgroup with progressive morbidity increase (64% at guideline age, 85% at grade 3; P = .002), inflecting near age 12 years. Left-to-right shunt lesions showed forward morbidity accumulation (adjusted OR, 1.05 [1.01-1.09]; P = .03). Resource utilization rose with delay overall (adjusted OR, 1.04 [1.01-1.07]; P = .01) and in left-to-right shunt and transposition physiology, but fell in cyanotic and Fontan-stage groups. CONCLUSIONS: Three in four children missed their guideline window. Operative mortality did not rise with delay, which reflects case-mix confounding rather than evidence that delay is safe, since the youngest and sickest children are operated first. Morbidity rose with delay in Fontan-stage and left-to-right shunt physiology. Physiology-specific grading supports surgical decision-making when a child presents late.