The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery
Authors: Nasr Viviane G. , Staffa Steven J. , DiNardo James A. , Faraoni David 
Published: May 2021

BACKGROUND:
The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity.

METHODS:
This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012–2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching.

RESULTS:
A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05–1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08–1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19–1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05–1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19–1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05–1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37–2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11–1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29–3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08–1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11–1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60–1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86–1.36; P = .517) nor the components of the composite secondary outcomes.

CONCLUSIONS:
Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.