Over 300 Deaths While Waiting: Portugal's Cardiac Surgery Crisis and What Changes Are Coming

A Public Health Crisis Unfolding in the Cardiac Unit

Between 2021 and 2025, Portugal's cardiac surgery divisions recorded 328 patient deaths among those on surgical waiting lists—a figure that underscores significant challenges within the country's cardiac care system. This week, as State Secretary for Health Ana Povo testified before parliament, the government outlined concrete proposals: plans to restructure cardiac surgery networks and introduce affiliated surgical hubs designed to reduce pressure on the country's northern hospitals.

Key Takeaways

• 328 deaths recorded: An average of approximately 66 annual fatalities between 2021-2025, with 2024 recording the highest toll at 71

• 1,387 patients waiting beyond recommended times: As of mid-2025, a significant portion of cardiac surgery candidates had exceeded safe clinical wait times

• Geographic disparity: The North region faces the most acute challenges, with limited surgical capacity serving a large population base

• Affiliated model proposed: The government plans to formally consider "affiliated cardiac centers" that can perform minimally invasive procedures (TAVI) through partnership with existing referral hubs

The Scale of the Crisis

The mortality figures reflect real pressures within the system. ULS Santo António in Porto, one of the North's largest public hospitals, faces significant demand for cardiac services. In discussions about expanding capacity, the hospital's situation illustrates systemic constraints: a cardiac surgeon hired in 2016 remains contractually employed yet unable to perform procedures because regulations require a team of at least two specialists for any surgical intervention.

This regulatory framework was established with specific intentions—to ensure surgical safety through team-based care—but creates practical constraints in hospitals where staffing remains limited despite existing contractual commitments.

A Network Misaligned with Reality

Portugal currently operates six public cardiac surgery centers, concentrated primarily in Lisbon and the North. The sector is supplemented by 11 private surgical facilities, yet the public system doesn't fully leverage private capacity.

According to Povo's parliamentary testimony, private surgeries performed through Portugal's unified surgical waiting-list system (SIGIC) represent a small fraction of total private surgical activity, indicating that private hospitals prioritize paying patients and remain largely autonomous from public queue management. The government has tasked the Health Regulatory Authority (ERS) with auditing private cardiac surgery organizations to explore potential for increased public case integration.

Patient cases are currently routed through ULS São João, ULS Vila Nova de Gaia/Espinho, and ULS Braga, the latter having recently opened. The new Braga facility is working to expand capacity toward full operational capability.

The Waiting List as a Public Health Measure

By mid-2025, 2,437 patients were on cardiac surgery waiting lists nationwide, with more than half exceeding Maximum Guaranteed Response Times (TMRG). For urgent-priority cases, the clinical standard permits a 30-day maximum, while routine cases should be addressed within 90 days. Exceeding these timelines incrementally increases clinical risk.

Approximately 56% of cardiac surgery candidates are currently waiting beyond recommended limits, reflecting the systemic backlog.

The TAVI Bottleneck Explained

Transcatheter aortic valve implantation (TAVI) is a catheter-based procedure requiring no surgical incision, only imaging guidance through a groin access point. It's ideal for elderly or high-risk patients unable to tolerate open-heart surgery. However, Portugal's Directorate-General for Health (DGS) mandates that any facility performing TAVI must maintain on-site surgical team capability for emergency intervention.

The consequence is that any hospital wanting to offer TAVI must also be a full cardiac surgery center, with complete surgical infrastructure and multidisciplinary teams. This regulatory requirement prevents non-surgical hospitals from offering the minimally invasive alternative, effectively confining TAVI to already-saturated surgical hubs.

Santo António illustrates this problem directly: the hospital has a cardiac surgeon on payroll and interventional cardiologists trained in TAVI, yet cannot proceed because the single surgeon doesn't meet team requirements. This regulatory constraint prevents capacity expansion despite available expertise and staffing.

Proposed Remedy: The Affiliated Model

Rather than authorizing Santo António as a standalone cardiac surgery center—requiring significant institutional investment and potentially dispersing specialized staff—Povo is proposing an alternative: affiliated cardiac surgery units linked to existing referral hubs.

Under this framework, Santo António would partner with an established center (likely São João in Porto) and operate as an extension of that facility. Open-heart surgical cases would remain at the referral hospital, but TAVI placements and certain interventional procedures could occur at the affiliate, expanding regional capacity without fragmenting the surgical workforce.

The proposal centers on a practical consideration: modest additional staffing at existing satellite facilities could unlock significant gains in throughput and regional access.

The model hasn't escaped criticism. Directors at São João and Gaia, along with the Portuguese Medical Association (Ordem dos Médicos), have cautioned that dispersing teams could weaken core centers. Cardiac surgery depends on highly specialized cohorts whose expertise deepens through sustained high-volume practice.

Impact for Patients and Residents

For anyone living in Porto, Braga, or Vila Real with cardiac disease, the current system creates significant delays. A patient deemed "routine priority" can deteriorate unpredictably over months of waiting, crossing into emergency territory without warning. The practical reality means residents face extended waits while their clinical condition may be changing.

Residents can check their position in the queue through the eSIGIC portal on SNS 24, though current information often reflects substantial delays rather than reassurance of timely care.

For those with financial means, private hospitals offer alternatives with typically shorter wait times. That bifurcation creates equity concerns: public patients wait substantially longer than private patients with identical medical conditions.

Legislative Movement Underway

Health Minister Ana Paula Martins signaled that regulatory changes are underway. The government is drafting measures aimed at improving cardiac surgery wait times and has announced plans for a formal decree reviewing the entire cardiac surgery referral network, incorporating provisions for affiliated centers and expanded capacity.

The statute of limitations on addressing these delays is measured in lives. The ongoing mortality pattern underscores the urgency of implementing reforms to improve access and reduce waiting periods.

Political Undertones and Conflicts of Interest

Povo's testimony this week included a defense against conflict-of-interest suggestions. She previously worked at ULS Santo António before joining the government, and critics have questioned whether her advocacy for expanded capacity there reflects institutional loyalty rather than objective policy analysis.

Her counter-argument addresses the broader challenge: healthcare professionals transitioning to government roles will inevitably have prior institutional experience. She noted that precedent exists—former Health Ministers similarly came from medical institutions—suggesting that uniform application of conflict-of-interest standards across the sector remains an open governance question.

Povo clarified that government documentation on Santo António's potential expansion "is not a decisory document"—meaning the government hasn't unilaterally authorized the facility as a new referral center, but rather opened it for evaluation and recommendation by relevant bodies.

What Comes Next

The government is moving forward with regulatory review and reform of the cardiac surgery referral network. Regional hospitals in the North are preparing documentation for affiliated-center status. The ERS regulatory assessment of private-sector capacity should inform strategies to increase SIGIC utilization.

For patients currently on waiting lists, those exceeding the 90-day clinical limit should engage with their physician or hospital administrator about available options—whether formal complaints to the ERS, requests for priority review, or consideration of private alternatives if feasible.

The eSIGIC system remains the primary tool for tracking queue position and estimated wait times, and patients are advised to monitor it regularly and communicate with their referring cardiologist about significant delays.

Portugal's cardiac surgery crisis reflects a healthcare system managing demand within existing infrastructure constraints. The proposed affiliated-center model represents a pragmatic approach to expanding capacity through partnership rather than complete institutional reconstruction. Whether reforms arrive with sufficient urgency to reverse current mortality trends remains a critical question for residents across the country.