Outcomes of congenital heart disease procedures in Pakistan: a retrospective cohort study using a publicly funded congenital heart surgery programme registry.
In a publicly funded congenital heart surgery programme in Pakistan, outcomes were influenced by procedural complexity and clinical factors rather than socioeconomic status once access to care was achieved, suggesting that publicly financed congenital heart disease programmes can deliver equitable short-term outcomes.
Key Findings
Results
Overall mortality increased significantly with procedural complexity, ranging from 1.46% in RACHS category 1 to 30.23% in RACHS category 4.
5431 patients underwent 5744 procedures between January 2024 and August 2025 across multiple public and private hospitals in Punjab, Pakistan.
Procedural complexity was classified using the Risk Adjustment for Congenital Heart Surgery (RACHS) system.
The difference in mortality across RACHS categories was statistically significant (p<0.001).
On multivariable analysis, each increase in RACHS category was associated with higher odds of mortality (adjusted OR 2.08, 95% CI 1.57 to 2.76).
Results
Urgent procedures were independently associated with increased in-hospital periprocedural mortality.
Urgent procedures had an adjusted odds ratio of 1.68 for mortality (p=0.046).
This association was identified through multivariable logistic regression accounting for clustering at the patient level.
The finding held after adjustment for procedural complexity and other covariates.
Results
Socioeconomic status was not independently associated with in-hospital periprocedural mortality.
Socioeconomic status was assessed using Proxy Means Test scores.
After multivariable adjustment, no significant independent association between socioeconomic status and mortality was detected.
The authors interpret this as evidence that publicly financed programmes can deliver equitable short-term outcomes once access to care is achieved.
Results
Higher procedural complexity, treatment in public hospitals, and greater distance-to-care were associated with prolonged hospital length of stay.
Multivariable linear regression was used to evaluate risk-adjusted associations with length of stay.
Treatment setting (public vs. private hospital) was a significant predictor of longer LOS.
Greater geographic distance to the treating facility was also independently associated with longer LOS.
These system-level factors were identified as continuing to influence resource utilisation even when mortality outcomes were equitable.
Methods
The cohort was predominantly paediatric, with the majority of procedures being surgical rather than catheter-based.
A total of 5431 patients underwent 5744 procedures.
87.1% of the cohort was paediatric, with a median age of 6.0 years.
55.3% of procedures were surgical and 44.7% were catheter-based.
The study used a retrospective cohort design based on the Chief Minister's Congenital Heart Surgery Program (CMCHSP) registry.
What This Means
This research examined outcomes for over 5,400 patients with congenital heart disease (heart defects present from birth) who received treatment through a government-funded programme in Punjab, Pakistan, called the Chief Minister's Congenital Heart Surgery Program. The study looked at who died during or shortly after their procedure and how long patients stayed in the hospital, and then investigated what factors were linked to worse outcomes. The programme covered both surgical operations and catheter-based (minimally invasive) procedures, and most patients were children with a median age of 6 years.
The study found that the main driver of death was how complex the procedure was — patients undergoing the most complex operations were roughly 30 times more likely to die than those having the simplest procedures. Emergency or urgent cases also faced higher mortality risk. Importantly, a patient's socioeconomic background — measured using a poverty-scoring system — was not linked to a higher risk of dying once they had already gained access to care through the programme. Longer hospital stays were associated with more complex procedures, being treated in a public (versus private) hospital, and living farther from the hospital.
This research suggests that publicly funded healthcare programmes for congenital heart disease can, at least in terms of short-term survival, provide fair outcomes regardless of patients' financial circumstances. However, system-level challenges — such as inequalities between public and private hospitals and the burden of travelling long distances for care — still affect how long patients spend in hospital and likely affect overall resource use. The findings highlight the potential value of government-funded programmes in reducing health inequities in low- and middle-income settings, while also pointing to areas like hospital infrastructure and geographic access that still need improvement.
Malik M, Fatimi A, Shah S, Khan M, Rasool F, Waqar T, et al.. (2026). Outcomes of congenital heart disease procedures in Pakistan: a retrospective cohort study using a publicly funded congenital heart surgery programme registry.. BMJ open. https://doi.org/10.1136/bmjopen-2026-125110