Heart surgery delays will cost lives, warns research

Pandemic has delayed lifesaving treatment for thousands of people with severe aortic stenosis.

Our approach does not put the onus on only management or doctors, but creates a joint solution that is easier to implement in practice

Feryal Erhun

Urgent action is needed to clear the backlog of people with a common heart condition who are waiting for lifesaving treatment, according to research published in the journal BMJ Open. The researchers have warned that a lack of action could result in thousands of people dying while waiting for treatment.

The COVID-19 pandemic has led to thousands of heart procedures being postponed and record waiting lists. Previous work has estimated that 4,989 people in England with severe aortic stenosis missed out on life-saving treatment between March and November 2020.

Aortic stenosis develops when the heart’s aortic valve becomes narrowed, restricting blood flow out of the heart. Prompt treatment is vital for people diagnosed with severe aortic stenosis, as around 50 percent will die within two years of symptoms beginning.

Now, an international team of researchers, including from the University of Cambridge, has modelled the impact that increasing treatment capacity and using a quicker, less invasive treatment option would have on waiting lists. Even in the best-case scenario, they found that the waiting list would take nearly a year to clear and over 700 people would die while waiting for treatment. The research was funded by the British Heart Foundation and the EPSRC Cambridge Centre for Mathematics of Information in Healthcare.

The traditional treatment for aortic stenosis involves replacing the narrowed valve, most commonly through open-heart surgery (a surgical aortic valve replacement, SAVR). However, a newer keyhole procedure called a transcatheter aortic valve implantation (TAVI) is increasingly being used and is now recommended for patients aged 75 and over.

The researchers investigated the impact that increasing treatment capacity and converting a proportion of operations to the quicker TAVI procedure would have on the backlog. They looked at how long it would take to clear the backlog and the number of people who would die while waiting for treatment.

They found that the best and most achievable option involved a combination of increasing capacity by 20 percent and converting 40 percent of procedures from SAVR to TAVI. This would clear the backlog within 343 days with 784 deaths while people wait for treatment.

“This simple yet relevant model tackles the critical question of how to clear waiting lists and is easy to interpret in practice,” said study co-author Professor Houyuan Jiang from Cambridge Judge Business School.

The team say they want to see greater collaboration at local and national levels to agree the changes needed that can ensure that people with severe aortic stenosis receive life-saving treatment as quickly as possible.

Before the pandemic around 13,500 SAVR and TAVI procedures were performed each year across the UK. Increasing capacity by 20 percent would represent one or two additional TAVI procedures each week per centre.

“We think that with local and national collaboration this increase is achievable,” said study co-author Professor Mamas Mamas from Keele University. “Furthermore, we have created an algorithm that NHS Trusts can use to work out the best approach locally.

“Since November 2020 the UK has been hit with further waves of COVID-19 which have led to extreme pressure on the NHS and additional delays to treatment. We expect that number of people waiting for treatment in recent months will be even higher than the figure we used in our study. Doing nothing is simply not an option. If we continue as we are currently thousands of people will die from untreated aortic stenosis.”

“Our approach does not put the onus on only management or doctors, but creates a joint solution that is easier to implement in practice,” said co-author Professor Feryal Erhun, from Cambridge Judge Business School.

“As this modelling study shows, even increased use of this quicker and less invasive procedure won’t be enough to overcome the impact of COVID-19 related delays and stop people with aortic stenosis dying while waiting for treatment,” said Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation and consultant cardiologist. “Cardiac care can’t wait. The NHS desperately needs additional resources to help it tackle the backlog of care and ensure that heart patients receive the treatment and care they need.”

Reference:

Christian Philip Stickels et al. ‘Aortic stenosis post-COVID-19: a mathematical model on waiting lists and mortality.’ BMJ Open (2022). DOI: 10.1136/bmjopen-2021-059309

Adapted from a BHF press release.

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