Correct Timing for Congenital Heart Surgery

The correct timing for congenital heart surgery is set by the natural history of each defect (how it behaves if left untreated), not by a child's age or weight. Among the common defects, only an atrial septal defect is best left until the age of three to four years. Almost every other condition needs surgery within the first year of life, and several need it at diagnosis.

That was the central argument of Dr. Aseem R. Srivastava, Chief – Pediatric CTVS & Chief – Adult CTVS, Artemis Hospitals, Gurugram, India, in his August 2025 masterclass for doctors across Africa. Dr. Srivastava trained in medicine and cardiac surgery in India, then spent about three and a half years in the United States, with fellowships at the Children's Hospital of Philadelphia and the Children's Hospital of Pittsburgh and further training in robotic cardiac surgery in North Carolina. He returned to establish the paediatric cardiac surgery programme at Artemis about ten years before the session. His team now treats children from India and around 17 other countries, and the issue he meets most often across all of them is the same one: timing, because the outcome of surgery depends heavily on when the child reaches the team.

Why "wait until the child is bigger" is the wrong rule

Referring doctors and families in many health systems share a belief that a child must reach a certain age or weight before cardiac surgery can be offered. Dr. Srivastava called this "absolutely wrong", and he was clear that the misunderstanding is not confined to India: it exists in the United States, Europe, the Russian Federation and the Middle East as well.

His reasoning turns on what the statistics leave out. A surgeon's operative mortality may well improve if he operates only on larger, older children. But the children who die while their families wait never reach the operating table, so they never appear in anyone's surgical results. A programme that waits looks safer on paper while losing more children in practice.

The alternative he set out is a simple comparison: the risk of death without treatment against the risk of treatment itself. Where a condition kills quickly, the comparison favours early surgery, whatever the child weighs. Where the natural history is benign for several years, as with an atrial septal defect, there is room to wait. Every recommendation in the masterclass followed from that one principle.

Congenital heart surgery timing by defect

Each defect has its own window: from surgery at diagnosis for TAPVR, truncus arteriosus and coarctation to elective closure at three to four years for an ASD. The table below summarises the timing Dr. Srivastava recommended for each condition, alongside the untreated natural history he presented. Each defect is covered in depth in the two companion articles.

Pulmonary atresia and single ventricle conditions also belong in the "treat at diagnosis" group: their treatment begins as soon as the diagnosis is made.

The acyanotic defects (those that do not usually make a child blue), the "holes in the heart" and the narrowed aorta, are explained in ASD, VSD, AV canal, PDA and coarctation: the right age for surgery. The cyanotic conditions (those that lower the blood's oxygen and make a baby look blue) and other newborn-critical conditions, including the Rastelli and Nikaidoh operations for complex transposition, are covered in TGA, tetralogy of Fallot, TAPVR and truncus: timing of surgery.

Late presentation: when is a child still operable?

Many late-presenting children are still operable. PDAs and most cyanotic conditions other than TGA can usually still be repaired, shunt lesions such as large VSDs are the group that become inoperable, and a cardiac catheterisation, not clinical impression alone, decides.

The question Dr. Srivastava's audience pressed hardest was what to do when the diagnosis comes late, as it often does where echocardiography is scarce. A paediatric cardiologist from Ethiopia described families who, faced with a late diagnosis, panic and ask to travel abroad for surgery.

Dr. Srivastava's first response was that the problem is shared. He described his own setting as resource-limited too: four or five specialists doing this work for the whole of northern India, roughly half of a very populous country. His team sees a late-presenting child every day or two, and he said plainly that he has not yet found a complete answer.

Which late presenters can still be operated on

His practical guidance grouped late presenters by type of defect:

• PDAs are usually still operable when they present late.
• Cyanotic ("blue") conditions other than TGA, such as tetralogy of Fallot, are usually still operable late, at a slightly higher risk.
• Shunt lesions such as VSDs are the group that, unfortunately, become inoperable.

"Inoperable" here has a specific meaning. A large left-to-right shunt exposes the lungs to high flow and pressure, and over months the small pulmonary arteries thicken until pulmonary vascular resistance is fixed and high. Once that happens, closing the defect no longer helps, because the right ventricle cannot pump against the lungs' resistance without the hole as an escape route. Defects that can produce this change early, such as large VSDs and AV canal defects, are the ones with a closing window.

Why he always offers a cardiac catheterisation

Clinical judgement alone, in Dr. Srivastava's experience, overcalls inoperability. When a child looks inoperable on clinical grounds, a cardiac catheterisation shows that a significant, though not large, proportion are in fact operable, at high risk. For that reason he always offers a late presenter a catheterisation to confirm before anyone gives up. Catheterisation measures pressures and pulmonary vascular resistance directly, and is the standard way to assess operability in this situation.

The stakes of getting this wrong showed in an example he gave from Uganda. The country's health ministry sends children to his team frequently, but many arrived too late: after catheterisation they were found to be inoperable and went home without treatment. When the minister visited, he asked Dr. Srivastava for a short guideline that non-medical officials, and doctors without congenital heart training, could use as a base document on when to refer. Dr. Srivastava wrote a four to five page document, which was translated into the local language, and he offered the English version to the doctors attending the masterclass.

When inoperability is confirmed

A confirmed inoperable result is not the end of care. Dr. Srivastava's advice is to counsel the family to stop running from centre to centre and to commit to skilled medical management. A child with an inoperable VSD who receives that care, meaning appropriately timed diuretics and appropriately timed pulmonary vasodilators, can still survive 25, 30 or 35 years. Without it, the same child dies much earlier. Even when surgery is off the table, the referring doctor can prolong life and improve its quality.

Earlier diagnosis starts with a pulse oximeter

Earlier diagnosis depends on education and routine pulse oximetry. Dr. Srivastava's longer-term answer to late presentation is education. His team has started education programmes in different centres, and when he speaks at a continuing medical education meeting he promotes pulse oximetry screening.

He urged paediatric cardiologists to help the paediatricians around them understand the significance of oxygen saturation measured at birth, at one month and at six months of age, so that a low reading triggers an early referral for echocardiography. Newborn pulse oximetry screening for critical congenital heart disease is now recommended in many countries; it is cheap and quick, and can detect critical conditions such as TGA before the baby becomes visibly unwell.

What a paediatric cardiac surgery programme needs

Good outcomes in complex congenital heart surgery depend on the whole system around the surgeon, not on the operation alone. Dr. Srivastava cited nine criteria from the British Medical Journal that a paediatric cardiac programme should meet, and said his team had spent ten years working to satisfy each of them and to match its infrastructure and outcomes with the Western world.

He described the five components of the Artemis programme:

• Womb to world. Mothers whose babies are diagnosed with a heart condition before birth come to the hospital, deliver there, and the baby moves straight to the paediatric cardiac intensive care unit for treatment and surgery before going home.
• Specialist clinics for heart failure, fetal cardiology, pulmonary hypertension, arrhythmias and pacemakers, adult congenital heart disease and heart valves.
• Advanced heart failure care, including transplantation, paediatric ventricular assist devices (mechanical pumps that support a failing heart) and extracorporeal membrane oxygenation (ECMO, a heart-lung bypass circuit used at the bedside).
• Treatment for primary pulmonary hypertension and cardiac resynchronisation therapy (CRT).
• A dedicated team of about 40 healthcare providers caring for children with heart conditions.

The hospital itself has more than 750 beds, 12 centres of excellence, more than 40 medical specialties and about 400 doctors, and is accredited by Joint Commission International (JCI).

Cost, referral and follow-up for international families

On cost, Dr. Srivastava put the average cost of ASD closure at approximately USD 5,500. Indicative ranges sit on the ASD closure cost and paediatric congenital heart surgery cost pages.

He was equally clear that treating a child is not a one-time event. His responsibility, as he described it, is to make sure the child is safe before surgery and that the doctors caring for the child afterwards have easy access to him. The session's moderator raised a common situation: a child who needs referral but whose family cannot afford surgery, and who must be managed locally with specialist guidance. Dr. Srivastava told referring doctors that he is available to them around the clock for guidance, even if he answers a little late when his schedule is tight, and that it makes no difference whether the child eventually comes to him or goes to another centre.

The questions African doctors raised during the session, including timing for TGA with left ventricular outflow tract obstruction and the care of late presenters, are recorded in the live discussion from this masterclass. For more on the specialty, see the cardiology hub.

The principle to carry into practice

The single message of the masterclass is that a congenital heart defect has a clock, and the clock differs by defect. An ASD allows three or four years. A large VSD allows months. A complete AV canal defect allows a few months before the lungs are damaged. TGA with an intact septum allows about two weeks, and TAPVR, truncus arteriosus and coarctation call for surgery at diagnosis. A referring doctor who knows which clock is running, and who refers by that clock rather than by the child's weight, prevents the deaths that never show up in surgical statistics.