Background: Congenital heart disease (CHD) carries substantial morbidity and mortality in sub-Saharan Africa, where delayed diagnosis and the absence of local cardiac surgery compound adverse outcomes. In Gabon, patients requiring surgical repair must be evacuated abroad. This study aimed to identify clinical and biological factors independently associated with complications and in-hospital mortality in this population.

Methods: Retrospective multicentre analytical cohort study (2021-2023), N = 72 CHD patients evacuated from Gabon for cardiac surgery. Complications (n = 22/69; 31.9%) and death (n = 11/70; 15.7%) were the primary outcomes. Univariate associations were assessed by chi-square or Fisher's exact test. Binary logistic regression identified independent predictors of complications (rule of ten events per variable).

Results: On univariate analysis, significant predictors of complications included: cyanotic CHD (OR 3.09; 95% CI 1.09- 8.75; p = 0.031), pulmonary atresia (OR 10.89; p = 0.028), respiratory distress (OR 13.06; 3.10-54.97; p < 0.001), oxygen desaturation (OR 4.80; p = 0.003), pre-operative cardiac failure (OR 3.80; p = 0.011), and polycythaemia (OR 8.95; p = 0.002). VSD was protective (OR 0.17; p = 0.006). On multivariate analysis, independent predictors of complications were respiratory distress (adjusted OR 16.42; 3.46-78.00; p < 0.001) and pre-operative cardiac failure (adjusted OR 4.99; 1.43-17.40; p = 0.012). All 11 deaths occurred in infants (≤ 24 months); univariate predictors of mortality included respiratory distress (OR 9.26; p = 0.003), pulmonary atresia (OR 11.06; p = 0.023), fever (OR 11.06; p = 0.023), and oxygen desaturation (OR 5.37; p = 0.028).

Conclusion: Respiratory distress and pre-operative cardiac failure independently predict complications in CHD patients evacuated from Gabon. In-hospital mortality is restricted to infants and is associated with markers of severe haemodynamic compromise. These findings support early referral, systematic pre-operative haemodynamic optimisation, and the urgent development of local paediatric cardiac surgical capacity.