The article discussed today reviews selected literature that reflects the evolution of congenital cardiac anesthesia as a subspecialty increasingly supported by multicenter registries, clinical trials, and clinical practice guidelines. This transition extends beyond anesthetic technique alone. It also encompasses risk stratification, perfusion targets, postoperative recovery, and the assessment of quality of care. The review addresses six major areas within the subspecialty, which are discussed below.
- Anesthesia for adults with congenital heart disease
Improved survival has resulted in a growing population of adults with congenital heart disease who require both cardiac and noncardiac interventions throughout their lives. Many of these procedures are performed outside specialist centers, making it essential to identify which patients can be safely managed in general hospitals and which require teams with specific expertise.
One of the highlighted studies analyzed more than 15,000 noncardiac procedures. Its findings demonstrated an association between anatomical complexity and perioperative risk. Patients with simple congenital heart disease had mortality rates similar to, or even lower than, those of the general population, whereas complications and mortality progressively increased among patients with moderate or complex disease.
US guidelines published in 2025 recommend that patients with moderate or complex anatomy should be managed by anesthesiologists with expertise in congenital heart disease, or in collaboration with them. They also recommend specialist preoperative assessment, risk stratification, multidisciplinary planning, and coordinated postoperative follow-up. Although many of these recommendations are based on expert consensus, they provide a common framework for organizing perioperative care.
That same year, the French Society of Anaesthesia and Intensive Care Medicine published its first guideline specifically addressing these patients. The document proposes a combined assessment of anatomical complexity, physiological status, and procedure-related risk. Integrating these factors helps determine the appropriate monitoring strategy, anesthetic technique, and postoperative recovery setting.
The review also reports the outcomes of almost 20000 cardiac procedures performed in adults with congenital heart disease in Japan. Overall mortality was 1.1%, but varied considerably according to the intervention, ranging from 0.07% for atrial septal defect closure to approximately 5% for aortic arch repair or ventricular assist device implantation.
Studies evaluating predictive models reached similar conclusions. Some scoring systems showed acceptable discriminatory performance but tended to overestimate mortality. Factors most strongly associated with complications included decompensated heart failure, active endocarditis, cyanosis, and previous sternotomies. In older patients, comorbidities such as diabetes and renal dysfunction also contributed. Although complications were more frequent in this group, 1-year mortality was not significantly increased among carefully selected patients.
- Cardiopulmonary bypass, inflammation, and coagulation
The second section focuses on the individualization of management during cardiopulmonary bypass. Moving beyond strategies based primarily on body surface area, temperature, and predetermined flow rates, several studies evaluated physiological variables that could allow perfusion to be tailored to the needs of each patient.
The most relevant study was a randomized clinical trial involving more than 300 children undergoing cardiac surgery. Conventional management was compared with a goal-directed perfusion strategy designed to maintain indexed oxygen delivery above a predefined threshold. This intervention reduced the incidence of acute kidney injury, with a more pronounced effect in children younger than 1 year, cyanotic patients, and those with low hemoglobin concentrations during cardiopulmonary bypass.
Achieving the oxygen delivery targets required the administration of more red blood cell concentrates. Therefore, the reduction in kidney injury was accompanied by greater transfusion exposure. The authors emphasize the need to determine which patients derive the greatest benefit and which threshold provides the optimal balance between organ protection and transfusion requirements.
Other studies examined circuit-associated inflammatory activation. Complement activation and elevated concentrations of several cytokines were detected in the prime before the patient was connected to the circuit, particularly when blood and fresh frozen plasma were included. These changes were also observed in circuits with biocompatible coatings.
Ultrafiltration of the prime reduced the concentrations of mediators such as IL-15, MCP-1, and VEGF by between 33% and 69%. Although this represents a relevant biological effect, it has not yet been demonstrated to reduce clinical complications. The authors therefore propose evaluating this intervention in multicenter studies using clinical outcomes.
Post-cardiopulmonary bypass coagulopathy is another central topic. Two studies assessed abnormalities that are not always detected by viscoelastic tests such as TEG or ROTEM. In one study, thrombin generation remained markedly reduced after heparin reversal with protamine. This reduction was associated with the total heparin dose and greater transfusion requirements. These findings indicate that persistent bleeding should not automatically be attributed to inadequate heparin reversal, as factor consumption during cardiopulmonary bypass may also contribute.
Another study examined fibrinolysis in infants receiving tranexamic acid. Despite prophylaxis, substantial activation persisted. However, patients with higher concentrations of plasmin–antiplasmin complexes experienced less bleeding. The investigators suggest that administered fibrinogen may act as a circulating substrate for plasmin, limiting its activity on the formed clot and promoting its neutralization by alpha-2-antiplasmin. This pathophysiological hypothesis requires confirmation in future studies.
- Perioperative corticosteroids
The review includes a dedicated section on three new analyses of the STRESS trial evaluating prophylactic methylprednisolone in infant cardiac surgery. The original analysis had not demonstrated a clear benefit using conventional statistical methods.
Studies published in 2025 found a reduced subsequent requirement for hydrocortisone, improved hemodynamic stability, and fewer reoperations for bleeding. Potential benefits were more apparent in neonates and term infants, patients without genetic syndromes, and those undergoing less complex procedures.
Adverse effects included increased hyperglycemia, greater insulin requirements, and more kidney injury. The association with kidney injury disappeared after adjustment for baseline renal function and blood glucose levels. This finding raises the possibility that part of the risk attributed to treatment may be related to its metabolic effects, although a causal relationship cannot be established. Premature infants showed a higher incidence of thrombotic events, leading the authors to recommend particular caution in this subgroup.
- Enhanced recovery after surgery
ERAS programs continue to expand in pediatric cardiac surgery, although their implementation remains heterogeneous. Two European surveys found that fewer than 40% of centers had a structured program. Individual interventions are frequently adopted, but fewer hospitals have comprehensive protocols and shared evaluation systems.
Early extubation is one of the most visible components of these programs. Studies published in 2025 support its safety in selected patients but report poorer outcomes in those with single-ventricle physiology, shunt dependence, or highly complex congenital heart disease.
The authors emphasize that the success of an ERAS program should not be assessed solely by time to extubation or hospital length of stay. The objective is to promote physiological recovery, control pain, and prevent complications. Advancing extubation by a few hours has little value if it is subsequently followed by hemodynamic instability, low cardiac output, or inadequate analgesia.
Regional analgesia is one of the interventions with the most consistent results. Several trials evaluated pecto-intercostal fascial plane blocks, rectus sheath blocks, and erector spinae plane blocks. These techniques reduced pain and opioid consumption and facilitated early extubation. However, most studies involved low-risk patients, and their applicability to more complex procedures remains uncertain.
Simple postoperative measures were also evaluated. Early chest tube removal improved comfort and reduced drain duration without increasing complications, although it did not significantly shorten length of stay. A meta-analysis found no relevant differences between high-flow nasal cannula and noninvasive ventilation in preventing respiratory failure and reintubation.
- Safety outside the cardiac operating room
Children with congenital heart disease increasingly require procedures outside the cardiovascular setting. Although many are minor interventions, their anesthetic risk remains higher than that of the general pediatric population.
A study involving more than 660,000 procedures examined the relationship between hospital volume and outcomes. The highest mortality was not observed in the lowest-volume centers, but rather in those with intermediate volumes. Hospital volume therefore showed no linear association with outcomes. The authors suggest that patient complexity, the availability of specialist professionals, and rescue capability may help explain this finding.
Another multicenter registry analyzed more than 6400 noncardiac procedures. Approximately 5% were associated with an intraoperative cardiovascular event, most commonly hypotension. Cardiac arrest was uncommon, with an incidence of approximately 0.2%. Complex congenital heart disease, preoperative hospitalization, and concurrent respiratory infections were associated with greater risk.
No differences were observed between cardiac anesthesiologists and general pediatric anesthesiologists. The authors caution that this finding may be influenced by patient selection: more complex cases are generally assigned to specialist professionals, whereas lower-risk patients may be managed by general pediatric anesthesiologists.
Safety has also improved in the cardiac catheterization laboratory. A study of more than 38000 catheterizations reported an incidence of severe anesthesia-related complications below 1%, lower than that described a decade earlier. The authors associate this improvement with risk-stratification tools, standardized protocols, and better communication among professionals.
The Congenital Cardiac Anesthesia Society proposed five indicators for assessing quality of care: the quality of handover to intensive care, infection prevention, blood conservation strategies, early extubation when appropriate, and the incidence of cardiac arrest during anesthetic care. Their use could facilitate comparisons between centers and support the development of quality-improvement programs.
- Sustainability of the subspecialty
The final section addresses the future availability of specialist anesthesiologists. A US survey found limited representation of professionals in the middle stages of their careers and showed that nearly one-third of respondents were considering leaving the subspecialty.
According to the estimates reported by the authors, approximately 200 new pediatric cardiac anesthesiologists will be required over the next decade. Specialist training must therefore be accompanied by measures aimed at improving retention and preserving the experience accumulated by senior professionals.
COMMENTARY:
The review portrays a subspecialty beginning to move beyond a period dominated by uniform protocols and decisions based primarily on experience. However, the most important change is not simply the availability of more publications, but the recognition that patients with the same diagnosis may have different risks and that an intervention may offer different benefits and costs depending on age, physiology, surgical complexity, and institutional resources.
Individualization emerges as the common denominator across the principal studies. In adults with congenital heart disease, anatomy alone is no longer sufficient to determine risk; physiological status and the planned procedure also matter. During cardiopulmonary bypass, flow is increasingly considered in relation to oxygen delivery. Within ERAS pathways, early extubation loses value as an isolated endpoint and becomes part of a broader strategy. Even outside the cardiac operating room, hospital volume alone is insufficient to explain outcomes without considering specialization, infrastructure, and rescue capability.
This progress requires a clear distinction between changing a marker and genuinely improving patient outcomes. Reducing cytokine concentrations in the prime does not yet equate to preventing complications. Increasing oxygen delivery may reduce kidney injury but also increase transfusion exposure. Earlier extubation does not necessarily represent better recovery. Increasing methodological sophistication must therefore be accompanied by equally rigorous interpretation.
The review also reminds us that standardization and individualization are not opposing concepts. Protocols provide a shared framework, reduce unjustified variability, and make outcomes measurable, whereas individualization determines when and how those protocols should be applied. Problems arise when a simple indicator—such as on-table extubation, hospital length of stay, or institutional volume—becomes an endpoint in itself.
Finally, no innovation can be separated from the system responsible for implementing it. Guidelines, trials, and registries may define safer care, but their impact will depend on the availability of specialist professionals and structures capable of coordinating complex decisions. The impending workforce shortage is therefore not a peripheral issue included at the end of the review. It is a factor that may determine whether the advances described reach patients or remain confined to the literature.
The overall assessment of 2025 is reasonably optimistic, but not complacent. Congenital cardiac anesthesia now has increasingly precise tools to guide decision-making. The next step will be to demonstrate that improvements in processes and intermediate markers translate into clinically meaningful, reproducible, and sustainable outcomes. The subspecialty no longer needs evidence alone; it needs to convert that evidence into better decisions.
REFERENCE:
Goodmanson MM, Latham GJ. The Year in Review: Anesthesia for Congenital Heart Disease 2025. Semin Cardiothorac Vasc Anesth. 2026 Jun;30(2):115-125. doi: 10.1177/10892532261438993.
