Synopsis Patients with ACHD may have greater operative risk than patients without ACHD. The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac may be applied; however, those guide- lines may not apply directly. One must remain cognizant that there are differences in cardiac issues commonly present in patients with ACHD, such as mechanisms for ventricular dysfunction, type and mechanisms of arrhythmia, and the probability of coronary artery di- was developed prima- rily with evidence and experience derived from, and re- lated to, patients with acquired heart disease. Thus, the evidence supporting recommendations regarding risk indices and management strategies may not apply to many patients with ACHD. Recommendation-Specific Supportive Text 1. A checklist of issues to consider in the assess- ment and management of patients with ACHD undergoing noncardiac surgery is presented in Table 11. Patients with ACHD may present with nonroutine and unusual physiological challenges (eg, those related to fluid balance in the setting of single ventricle or the impact of vascular resistances on shunts in cyanotic Heightened surveillance may mandate extended postoperative intensive or other high-acuity care.S3.12-2 2. Case series and analysis of administrative databases confirm that surgical procedures in patients with ACHD carry greater risk than in patients without Risk relates to the specific type of ACHD, surgical procedure, urgency of intervention, and availability of specialized Noncardiac surgery is usually accomplished without substan- tial morbidity or mortality, but even minor sur- gery can be complicated in patients with ACHD. 