Major reallocation of healthcare services during the COVID-19 pandemic meant that elective surgery in children with congenital heart disease (CHD) was significantly reduced, so that those needing urgent, lifesaving and emergency surgery could be treated. However, this prioritisation of the most severely ill children did not increase overall post-operative complications rates or death, a study led by the University of Bristol has shown.

The research, published in Open Heart, suggests that prioritising surgery for younger and more critically ill children may be appropriate when there is a sudden disruption of usual care. The findings could be used as a preparedness model for future pandemic-like scenarios, such as natural disasters or healthcare disruptions.

During the early days of the SARS-CoV-2 pandemic, pressure on healthcare resources affected hospitals to treat COVID-19 patients and to postpone elective procedures like specialist surgeries for CHD in children. However, CHD children require several repeat surgeries to maintain a healthy heart structure and function as they grow.

The aim of the study was to assess, in children under 16 years old, the impact on CHD procedures in England during different pandemic periods compared with the pre-pandemic period, to inform appropriate responses to future major healthcare disruptions. The researchers also investigated whether there was an increase in post procedure complication and post procedure death during these periods when compared to the pre-pandemic period.

The researchers analysed 26,270 procedures from 17,860 children between 1 January 2018 and 31 March 2022 in England, linking them to primary/secondary care data. The study period included pre-pandemic and pandemic phases, with the latter including three restriction periods and corresponding relaxation periods. Procedure characteristics and outcomes between each pandemic period and the pre-pandemic period were compared.

The study found the median number of CHD procedures per week was lower during all pandemic periods compared to pre-pandemic levels. The largest reductions occurred during the first, most severe restrictions, and the relaxation period following the second restrictions, coinciding with winter pressures.

These reductions were primarily driven by reductions in elective procedures, while urgent and emergency/life-saving procedures remained stable compared to pre-pandemic rates. There was evidence of prioritising cardiac surgery over catheterisation and prioritising infants during the pandemic. Reassuringly, the research found limited evidence of increased post procedure complications or death during the pandemic compared to the pre-pandemic levels.

Dr Arun Karthikeyan Suseeladevi, Senior Research Associate in Medical Statistics and Health Data Science in Bristol Medical School: Population Health Sciences (PHS), and main author, said: “Our results suggest that when pressures on health services result in prioritisation of urgent, emergency and life-saving procedures in children with CHD and delaying elective procedures, this does not result in increased post procedure complications or mortality, over a period of two years.

“These findings have implications for future health service provision, particularly during infectious disease epidemics or global pandemics as well as during extreme weather events common across Europe.

“Notably, during the relaxation period following the second restriction, the median rates of overall and elective procedures dropped to levels similar to those in the first restriction period, exceeding the reductions seen during the second restriction. This second relaxation occurred during winter (3 Dec 2020 to 5 Jan 2021) and might reflect winter pressures.

“As climate change intensifies the frequency of weather extremes, such pressures are likely to rise, highlighting the need for strategies to mitigate climate change and effective plans to manage health services pressures from various sources.”

Professor Deborah Lawlor, British Heart Foundation Professor of Cardiovascular Science and senior author on the paper, explained: “These findings are reassuring whilst cautioning that they cannot tell us about what happened to individual patients. In particular, we need to explore what longer term effects there might be on the children whose surgery was delayed and their families. As we continue to collect more information data we hope to be able to determine whether those children and their families had any adverse heart or mental health effects from the delayed surgery.”

Massimo Caputo, Professor of Congenital Heart Surgery, and an author on the paper, added: “We also need to understand the impact of COVID-19 infection on children with CHD, particularly those who did have surgery and might have been exposed to the infection whilst in hospital.”

The study was supported by the British Heart Foundation Data Science Centre led by HDR UK (BHF Grant no. SP/19/3/34678), NIHR Bristol Biomedical Research Centre (BRC) and MRC Integrative Epidemiology Unit (IEU). The study makes use of deidentified data held in NHS England’s Secure Data Environment service for England and made available via the BHF Data Science Centre’s CVD-COVID-UK/COVID-IMPACT consortium.