Reducing anesthetic morbidity and mortality in children with heart failure undergoing non cardiac surgery: a physiology and equity focused approach

Children with heart failure increasingly present for non- cardiac procedures, yet they remain at high risk for peri- operative morbidity and mortality. Traditional lesion-fo- cused anesthetic approaches fail to capture the physio- logic vulnerability that drives adverse outcomes. This perspective synthesizes current evidence on perioperative risk, emphasizing physiology-based determinants—ven- tricular dysfunction, pulmonary hypertension, cyanosis, and recent decompensation—as stronger predictors than anatomic diagnosis alone. It highlights the critical role of preoperative optimization, multidisciplinary planning, and intraoperative strategies tailored to fragile cardiovas- cular physiology. Postoperative vigilance, extended mon- itoring, and system-level interventions are essential, par- ticularly in low-resource settings where structural inequi- ties exacerbate risk. By integrating a physiology-driven, equity-focused approach, anesthesiologists can anticipate instability, reduce preventable complications, and im- prove survival for this vulnerable population worldwide.