Urban–Rural and Racial Disparities in Paediatric Congenital Heart Disease Mortality in the United States, 1999–2020 : A National Surveillance Study

Background: Pediatric congenital heart disease (CHD) remains a major contributor to mortality in the United States. National trends by geography, sex, and race/ethnicity are not well characterized. This study aimed to identify temporal patterns in CHD-related mortality from 1999–2020 and to quantify disparities across urban–rural residence, sex, and race/ethnicity. Methods: We analyzed mortality data from the CDC WONDER database to calculate age-adjusted mortality rates (AAMRs), and annual percent changes (APCs) were estimated using Joinpoint regression. Results: Across the study period, 58,616 CHD-related deaths were recorded. Urban areas showed higher mortality rates than rural areas. Sex-stratified trends demonstrated sharper early declines among urban females (APC −2.51%) and a short-accelerated decline among urban males (APC −5.60%). Rural males and females showed similar long-term declines. Racial patterns revealed sustained reductions across all groups; however, rural White children showed a temporary increase (APC +4.11%), and Black children in both urban and rural areas consistently experienced the highest mortality and slowest improvement. Conclusions: Pediatric CHD mortality declined nationally from 1999–2020, but improvements were uneven. These findings highlight the need for targeted policy efforts to expand access to specialized cardiac care, optimize referral networks, and strengthen health infrastructure in underserved regions. Clinical trial number : not applicable.