Top Things to Know: Important Residual Lesions and Early Unplanned Reinterventions after Pediatric Cardiac Surgery

Updated: September 01, 2026

Prepared by John M. Costello, MD, MPH, FAHA

  1. An early unplanned cardiac reintervention refers to the unanticipated need for a surgical, catheter-based, or both types of procedures during the same hospitalization as the index operation. Common reasons include an incomplete preoperative diagnosis, a failed therapeutic plan, a suboptimal correction of the heart defect, or some combination of the above.
  2. Early unplanned cardiac interventions occur in approximately 5% of all cases; younger patients undergoing more complex operations are at greater risk. Wide center-level variation exists in the incidence of early unplanned interventions, highlighting an opportunity for collaborative learning.
  3. Future research is needed to develop high-risk prediction tools and care bundles to minimize the incidence and impact of important residual lesions. Efforts to expand pediatric cardiac surgical training to integrate emerging technologies such as simulation, video-based learning, and three-dimensional modeling may be beneficial.
  4. An early unplanned cardiac reintervention refers to the unanticipated need for a surgical, catheter-based, or both types of procedures during the same hospitalization as the index operation. Common reasons include an incomplete preoperative diagnosis, a failed therapeutic plan, a suboptimal correction of the heart defect, or some combination of the above.
  5. Early unplanned cardiac interventions occur in approximately 5% of all cases; younger patients undergoing more complex operations are at greater risk. Wide center-level variation exists in the incidence of early unplanned interventions, highlighting an opportunity for collaborative learning.
  6. Early unplanned cardiac interventions are associated with a 7-fold higher adjusted risk of hospital mortality. Important residual lesions and unplanned reinterventions are also associated with late morbidity and mortality, including worse neurodevelopmental outcomes.
  7. Residual Lesion Scores can be utilized to qualitatively assess the technical outcome of pediatric cardiac surgical procedures.
  8. Preoperative assessment requires the development of a complete and integrated understanding of cardiac anatomy and associated physiology. Multidisciplinary case conferences are important to ensure cardiac issues and any noncardiac comorbidities are fully appreciated, to discuss options for intervention, and to develop shared expectations and buy-in among care team members.
  9. Complex cases at high risk for unplanned reinterventions and operative mortality are ideally performed in comprehensive care centers that have the resources and expertise outlined in the Congenital Heart Surgeons Society 2023 Expert Consensus Statement.
  10. One of the most important aspects of postoperative care is the timely identification and management of important residual lesions. Patients who deviate from the anticipated postoperative course warrant an echocardiogram as well as thoughtful consideration of the need for cross-sectional imaging, cardiac catheterization, or both diagnostic modalities.
  11. Transcatheter interventions can be performed safely early after index operations but warrant careful multidisciplinary planning, including detailed discussion with the congenital heart surgeon and contingencies for hemodynamic instability.
  12. In patients who initially separate from cardiopulmonary bypass with significant residual lesions, the surgeon must consider the hemodynamic effect of the lesion, its amenability to an additional attempt at repair, and the morbidity associated with an additional bypass run. Although it is generally better to go back on bypass to repair major residual lesions than to manage those with residual lesions expectantly, these “on-the-spot" decisions are amongst the most complex a congenital heart surgeon has to make.
  13. Future research is needed to develop high-risk prediction tools and care bundles to minimize the incidence and impact of important residual lesions. Efforts to expand pediatric cardiac surgical training to integrate emerging technologies such as simulation, video-based learning, and three-dimensional modeling may be beneficial.

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Citation

Costello JM, Mazwi ML, Riley CM, Gonzalez de Alba CE, Olivieri LJ, Rigsby CK, Hill KD, Bacha E, Newburger JW; Nathan M; on behalf of the American Heart Association Congenital Cardiac Defects Committee; Council on Lifelong Congen¬ital Heart Disease and Heart Health in the Young; Council on Clinical Cardiology; and the Council on Cardiovascular and Stroke Nursing. Important residual lesions and early unplanned reinterventions after pediatric cardiac surgery: a scientific statement from the American Heart Association. Circulation. Published online September 1, 2026: doi: 10.1161/CIR.0000000000001465
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