Portugal's Cardiac Surgery Crisis: Why Waiting Lists Are About Appointments, Not Operating Rooms

Portugal's three leading cardiology chiefs have issued a stark warning against opening more cardiac surgery centers—directly contradicting Health Minister Ana Paula Martins's proposal announced just one day earlier.

Their reasoning? Portugal lacks sufficient cardiac surgeons, perfusionists, and specialist anesthetists to staff new centers without weakening existing ones.

The directors argue that new facilities would merely shuffle existing capacity rather than increase it, potentially fragmenting the National Health Service (SNS) at a time when consolidation is crucial.

The joint statement from Fausto Pinto (ULS Santa Maria, Lisbon), Lino Gonçalves (ULS Coimbra), and Ricardo Fontes Carvalho (ULS Gaia and Espinho) came just one day after Health Minister Ana Paula Martins publicly floated the possibility of authorizing additional cardiac surgery reference centers—provided technical experts agree. The three directors, who oversee Portugal's largest and most established cardiac departments, argue that such a move would be counterproductive.

The Staffing Math Doesn't Add Up

At the heart of their objection is a simple equation: Portugal does not have enough highly differentiated professionals to populate new surgical centers without pulling teams from existing ones. Cardiac surgery requires not just surgeons but a full complement of specialists—perfusionists who manage heart-lung machines during bypass, anesthetists trained in cardiovascular procedures, and intensive care units equipped for post-operative recovery.

"Creating or expanding activity outside the model established in 2023 will hardly increase the real capacity of the system," the directors wrote in their open letter. Instead, it risks "fragmenting teams, weakening consolidated centers, and reducing overall efficiency—precisely when effort should be concentrated where functional structures and proven results already exist."

This is not a theoretical concern. European best practice, validated by decades of outcome data, shows that high-volume cardiac surgery centers achieve lower mortality rates and better patient outcomes than dispersed, lower-volume facilities. Splitting Portugal's already stretched workforce would likely reduce surgical volumes at each site, undermining the quality and safety gains that centralization brings.

What the 2023 Network Was Built to Do

The three cardiologists emphasized that extensive groundwork has already been completed. The National Hospital Referral Network for Cardiovascular Care, published in 2023 by the Directorate-General of Health (DGS), was the product of independent technical evaluation and institutional consensus.

It designated specific hospitals as national reference centers, aligning Portugal with international standards that favor centralized, high-volume cardiac surgery hubs. Currently, the North region has three hospitals performing cardiac surgery: ULS Gaia and Espinho, ULS São João (Porto), and Hospital de Braga. In the Centre, ULS Coimbra is the primary center. In Lisbon and the South, ULS Santa Maria, ULS São José, and ULS Lisboa Ocidental hold reference status.

The directors argue that reinforcing these centers—expanding operating room capacity, hiring additional staff, and improving internal logistics—would deliver immediate gains without creating permanent new structural costs or scattering scarce expertise.

The Real Bottleneck: First Appointments, Not Surgery Slots

Perhaps the most pointed section of the open letter addresses a "rarely discussed" issue: patients are waiting months for initial cardiology consultations, long before they even reach the stage of needing surgery.

In several hospitals that publicly cite surgical waiting lists at other institutions, "significant delays" persist in accessing the first cardiology appointment, the directors note. "When the entry door fails, it creates artificial pressure at the most differentiated levels of care."

For residents unfamiliar with the SNS process: a first cardiology consultation requires a referral from your family doctor (médico de família). You cannot self-refer directly to a cardiologist in the public system. This gatekeeping structure means delays at the primary care level cascade throughout the system.

This is the key inversion of the public debate. Discussing surgical waiting lists before addressing primary cardiology access is "analyzing only the effect, not the cause," they wrote. A patient who cannot get a timely diagnostic consultation will not be referred for surgery at the appropriate clinical moment—delaying intervention until the condition worsens and creating the perception of surgical bottlenecks.

Data from the first half of 2025 illustrate the scale of the problem: 24,626 patients were waiting for a first cardiology consultation—a 140.9% increase in the queue. Of those, 83.7% had exceeded the legally guaranteed maximum response times (TMRG), which for cardiology first consultations is typically 150 days for routine cases.

Although 23,603 first cardiology consultations were completed in public hospitals during the same period—a 75.8% increase over 2024—87.4% of those consultations exceeded the TMRG. Cardiology is now one of the specialties with the longest access delays in the SNS, and the directors argue that no amount of surgical capacity expansion will resolve the underlying organizational and resource allocation failures.

Impact on Residents and Patients

For anyone living in Portugal and navigating the SNS for cardiac care, this debate translates into very practical concerns:

• Longer waits at every stage: If you're experiencing chest pain, shortness of breath, or other cardiac symptoms, the challenge isn't just getting onto a surgery list—it's getting a first appointment with a cardiologist to diagnose the issue and initiate treatment.

• Risk of clinical deterioration: Delayed diagnosis means delayed intervention. Conditions that could be managed with medication or minimally invasive procedures may worsen to the point where emergency surgery is needed, increasing risk and cost.

• Quality of care at stake: If new cardiac surgery centers open without new staff, the volume at established centers may drop, potentially affecting surgical outcomes and complication rates. Conversely, new centers staffed by teams pulled from existing hospitals may lack the cohesion and experience that high-volume centers provide.

The Portuguese Society of Cardiology published a strategic plan in 2025 that lamented the "social alarm" generated by waiting list headlines, arguing it diverts focus from the structural solutions needed: better hiring models, adequate funding for reference centers, and improved coordination between primary care and specialist services.

The North Region Crisis

The urgency of the debate intensified in recent weeks after four northern hospitals—Santo António (Porto), Vila Real, Tâmega e Sousa (Penafiel), and Matosinhos—sent a joint alert to the Health Minister warning of "patients at risk" due to months-long surgical queues.

André Luz, director of the Cardiology Service at ULS Santo António, revealed in an interview with RTP that 10 patients died over the past three years at his facility alone due to excessively long waiting lists. The Health Ministry responded by ordering an "urgent evaluation" by the SNS Executive Directorate and announced that the Regulatory Authority for Health (ERS) would investigate access constraints to cardiac surgery.

Minister Ana Paula Martins acknowledged in a parliamentary hearing in February 2026 that surgical waiting lists had grown despite an increase in procedures performed. New patient registrations for surgery rose by approximately 13,668, even though 10,600 more surgeries were completed compared to the previous period. By the end of 2025, more than 264,000 patients were awaiting surgery across all specialties in Portugal, a 3.4% increase from 2024, with 31% waiting beyond the TMRG.

The Minister's Response and Next Steps

In response to the mounting pressure, the Health Ministry has signaled openness to creating additional Integrated Responsibility Centers (CRI) for cardiac surgery—but only if the Directorate-General of Health and technical experts provide a favorable opinion.

Meetings are scheduled with the CRIs in the North (Braga and São João), Centre (Coimbra), and Lisbon (Santa Maria, São José, and Lisboa Ocidental) to develop a plan to reduce waiting lists. The cardiology directors' concern is that opening new centers would create permanent structural costs precisely when efficiency savings are being prioritized—potentially leaving both new and existing centers under-resourced.

A new national system for managing surgical and consultation waiting lists—SINACC—is set to replace the current SIGIC platform on 1 August 2026. The new system will allow patients to track their position in real time and introduce priority queues for oncology and cardiology cases, with a 30-day maximum wait for urgent procedures.

At the local level, some facilities are investing in cardiology infrastructure. The ULS Médio Tejo has earmarked €15 M of its €233 M budget for 2026 to upgrade the cardiology suite at Hospital de Abrantes, improving capacity for interventional procedures and cardiac patient follow-up.

What International Best Practice Suggests

European health systems with the best cardiac surgery outcomes share a common approach: concentrate procedures in high-volume centers and implement Enhanced Recovery After Cardiac Surgery (ERACS) protocols to shorten hospital stays and reduce complications.

Swiss centers, for example, discharge cardiac surgery patients in as few as 3 days using ERACS, which focuses on optimizing perioperative care without increasing mortality or complication rates. The model requires multidisciplinary training, institutional commitment, and a redesign of care pathways—all of which align with the argument for strengthening existing centers rather than dispersing resources.

The evidence is clear: surgical outcomes improve as center volume increases. Fragmenting Portugal's cardiac surgery network would move the country in the opposite direction, toward lower-volume sites that international data associate with higher mortality and longer recovery times.

What Residents Should Know

If you or a family member needs cardiac care in Portugal, here's what to expect in the coming months:

First consultation is the first hurdle. Don't wait for symptoms to worsen. Request a cardiology referral from your family doctor as soon as cardiac symptoms appear. The earlier you enter the system, the better your chances of timely diagnosis and treatment.

Track your position. Use the SNS 24 Portal to monitor your place in the queue for consultations and surgeries. The new SINACC system launching in August will provide more transparency.

Understand the reference network. If you're referred for surgery, you will likely be sent to one of the designated reference centers (Gaia, São João, Braga, Coimbra, Santa Maria, São José, or Lisboa Ocidental). These are the facilities with the highest surgical volumes and, according to international evidence, the best outcomes.

Private alternatives exist, but with caveats. Facilities like Hospital da Luz Lisboa (starting around €120-150 for cardiology consultation), Hospital Lusíadas Lisboa, and Hospital Cruz Vermelha offer cardiology services. If your wait exceeds the TMRG, you may be entitled to an SNS voucher (cheque-consulta) that covers private care at no additional cost—ask your family doctor or contact the SNS24 line (808 24 24 24) to verify eligibility.

The Unresolved Question

The core tension in this debate is whether Portugal can solve its cardiac surgery waiting lists by building more centers or by fixing the organizational, financial, and staffing problems that prevent existing centers from operating at full capacity.

The three cardiology directors have made their position unambiguous: without more specialized staff, new centers are a mirage. They argue that the immediate, cost-effective path forward is to reinforce the 2023 reference network, address the consultation bottleneck at the entry point of the system, and ensure that the centers already equipped and experienced can operate without artificial constraints.

The Health Ministry's decision—expected after consultations with the DGS and clinical experts—will determine whether Portugal doubles down on its existing infrastructure or disperses its limited cardiac surgery capacity across a wider geographic footprint. For patients waiting in the queue, the choice will have direct consequences for how quickly they receive care and how safe that care will be.