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. Surgery that is low risk in the general population may be associated with higher risk in the ACHD Patients with ACHD may present with nonroutine and unusual physiolog- ical challenges (eg, those related to fluid balance in the setting of single ventricle or the impact of vascular resistances on shunts in cyanotic When possible, patients with ACHD, especially those with complex disease (ACHD AP classifica- tion II and III) and/or whose disease has progressed (stages B, C, D) (Tables 3 and 4), should receive preoperative evaluation and surgery or other non- surgical intervention within an ACHD program. Because the inability to access resources or urgent conditions may preclude transfer or timely consul- tation, collaboration with members of the mul- tidisciplinary ACHD team may be helpful. Clear CLINICAL STATEMENTS AND GUIDELINES processes for timely consultation and support are needed to manage the physiological challenges presented by patients with ACHD related to fluid balance, vascular resistance, and shunts.S3.12-3,S3.12-4 A checklist of issues to consider in assessment and management of patients with ACHD undergoing noncardiac surgery is presented in Table 11. 3.13. Pregnancy, Reproduction, and Sexual Health Recommendations for Pregnancy Referenced studies that support recommendations are summarized in Online Data Supplement 19. 