Submitted:
11 January 2026
Posted:
12 January 2026
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Abstract
Armed conflicts disrupt healthcare systems, creating profound challenges for children with congenital heart disease (CHD). Time is a critical determinant of cardiac physiology, disease progression, and surgical feasibility. This editorial highlights how delays in diagnosis and treatment transform otherwise reversible conditions into advanced, irreversible, and life-limiting disease. Focusing on pulmonary vascular disease in neglected shunt lesions, truncus arteriosus, and left ventricular (LV) deconditioning in D-transposition of the great arteries (D-TGA), we outline the pathophysiological pathways through which delayed intervention limits therapeutic options. We also emphasize the ethical responsibility of the global pediatric cardiology community to develop wartime-resilient care models.
Keywords:
reversibility of congenital heart disease
; wartime ethics
Background: The Principle of Reversibility in Congenital Heart Disease
CHD are the most frequent congenital malformations, accounting for 0,8 1% of all the live born. Warfare exerts a devastating impact on children with congenital heart disease (CHD), a population uniquely dependent on early detection and timely intervention [1]. Congenital heart lesions follow very specific natural histories shaped by age-related changes in vascular physiology, myocardial conditioning, and cardiopulmonary adaptation. When war disrupts health systems, children lose access to screening, transport, and cardiac surgery, and these narrow therapeutic windows close. As a result, lesions that are fully correctable in infancy progress to irreversible cardiopulmonary disease, often transforming a surgically treatable condition into lifelong morbidity or early mortality. The central concept that emerges is that reversibility in CHD is time-dependent, and conflict settings accelerate the loss of this reversibility [2].
Reversibility refers to the capacity to restore normal or near-normal cardiovascular physiology if a lesion is corrected within the appropriate developmental window. Many congenital heart defects have a benign trajectory when repaired early but evolve into irreversible disease when diagnosis and treatment are delayed. Wartime conditions—marked by limited access to echocardiography, absence of referral pathways, and collapse of surgical services—push children far beyond the threshold at which surgery can restore normal physiology. This phenomenon is illustrated starkly in three clinical contexts encountered frequently in war-affected regions.
Main Body
1. Pulmonary Vascular Disease in Neglected Left-to-Right Shunt Lesions (accounting for 20-40% of CHD)
In peacetime, defects such as ventricular septal defects (VSD), patent ductus arteriosus (PDA), and complete atrioventricular septal defects (AVSD) are typically repaired within the first year of life. Early closure prevents the progression of pulmonary vascular remodeling and preserves normal pulmonary artery pressures. However, children growing up in war zones often present years after the optimal window has passed. Long-standing exposure to high pulmonary blood flow induces medial hypertrophy, intimal fibrosis, and progressive elevation of pulmonary vascular resistance. Once resistance approaches systemic levels, physiology becomes irreversible, and Eisenmenger syndrome develops. At this stage, shunt closure is contraindicated and survival is significantly reduced, leaving transplantation as the only theoretical solution—an unavailable option in most conflict settings. Thus, a curable lesion becomes an untreatable chronic disease solely due to delay. [3,4]
2. Truncus Arteriosus: When Delay Means Loss of Operability
Truncus arteriosus is a lesion that demands early neonatal intervention. Ideally, repair is performed within the first few weeks of life, before the onset of accelerated pulmonary vascular disease and long-term damage to the truncal valve. In wartime, newborns with truncus arteriosus rarely receive timely diagnosis or referral. By the time they reach medical attention, severe pulmonary hypertension, significant truncal valve regurgitation, ventricular dilation, and malnutrition are often already established. These late changes dramatically increase surgical risk, and for many children, operative repair becomes either extremely hazardous or no longer feasible. A condition that is surgically correctable in early infancy becomes effectively lethal when health systems collapse [5,6].
3. Left Ventricular Deconditioning in Unoperated D-Transposition of the Great Arteries (D-TGA) the most frequent cyanotic CHD
The arterial switch operation (ASO) for D-TGA must be performed within the first 2–3 weeks of life. During this period, the left ventricle (LV) is still adapted to systemic pressures, a remnant of its intrauterine hemodynamic load. When surgery is delayed, the ductus closes, LV pressure drops, and the LV remodels into a thin-walled chamber suited only for pulmonary circulation. Once this deconditioning occurs, the LV is no longer capable of supporting systemic output, making a late ASO dangerous without a formal LV retraining process—something rarely available in conflict zones. As a result, many children receive atrial switch procedures (Mustard or Senning), which provide survival but lead to lifelong risks of systemic right ventricular failure, arrhythmia, baffle obstruction, and reduced exercise tolerance. The delay robs these children of the only truly physiological repair.
Wartime Cardiology: Beyond Physiology—Ethical and Systemic Obligations
The challenges of pediatric cardiology in wartime extend beyond individual lesions. Conflict dismantles the entire continuum of care—from prenatal diagnosis to neonatal stabilization, transportation, surgery, and long-term follow-up. Many children never undergo newborn screening, specialists are inaccessible, and parents lack safe transport to referral centers. Malnutrition, infections, and unstable living conditions further worsen surgical outcomes. These realities impose a moral responsibility on the global pediatric cardiology community to develop wartime-resilient strategies: remote echocardiography programs, emergency evacuation pathways for time-critical lesions, local provider training for duct-dependent stabilization, and humanitarian surgical missions with clear operability criteria. Without such systems, the burden of irreversible CHD will continue to escalate [7,8].
Conclusion
War deprives children with congenital heart disease of the most vital therapeutic resource: time. Delays in diagnosis and treatment transform reversible neonatal and infant lesions into advanced, irreversible physiologies. The progression of neglected shunt lesions to Eisenmenger syndrome, late-presenting truncus arteriosus, and LV deconditioning in unoperated D-TGA represent some of the most visible consequences of these delays. The pediatric cardiology community must prioritize systems that preserve operability windows, ensure timely intervention, and protect children from preventable cardiac deaths—even in the most unstable circumstances. Safeguarding reversibility in CHD is not simply a clinical objective; it is a humanitarian necessity.
Institutional Review Board Statement
not applicable as this study is a hypothesis/Review article.
Informed Consent Statement
not applicable as this study is a viewpoint/editorial.
Data Availability Statement
All data is made available within the manuscript and are owned by the authors.
Acknowledgments
To every child who is struggling for basic needs during wartime.
Conflicts of Interest
The authors declare no conflict of interest. The manuscript is submitted under Creative Commons Licensing CC-BY-NC-ND. A large language model has been used to proofread the article.
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