When Does the Heart Need Surgery? An Honest Conversation with a Cardiac Surgeon

Interview with Maksud Marufovich Muradov, Head of the Cardiac Surgery Department

Cardiovascular diseases remain the leading cause of death worldwide. According to the World Health Organization, in 2022 alone they were responsible for approximately 19.8 million deaths, accounting for around 32% of all deaths worldwide.

But behind these figures are not only heart attacks and emergency situations. In some patients, the coronary arteries gradually become narrowed; in others, the heart valves stop functioning properly; and some people live with heart disease for years without realizing that surgical treatment may eventually become necessary.

The words “heart surgery” still cause significant fear. Patients are concerned about virtually everything: Will the heart be stopped during surgery? How high is the risk? Can surgery be avoided? Which valve should be chosen? And will a person be able to return to normal life after surgery?

The most important questions about modern cardiac surgery are answered by Maksud Marufovich Muradov. Вставленный текст

— Maksud Marufovich, at what point in cardiac treatment does a cardiac surgeon become involved? When are medications no longer enough?

— Yes, one of the most common misconceptions is that a cardiac surgeon only becomes involved when medical treatment has “failed.” In reality, surgery and medication are not competitors; they are different stages of one treatment strategy.

A cardiac surgeon becomes involved in three key situations:

1. When the possibilities of medication have been exhausted.

For example, in severe atherosclerosis of the coronary arteries or critical valve stenosis. Medication can lower blood pressure, heart rate, or cholesterol levels, but it cannot physically “dissolve” a dense plaque or widen a narrowed valve.

2. When there is a life-threatening risk that precedes the symptoms.

Sometimes a patient feels relatively well, but based on examinations such as echocardiography, coronary angiography, or CT, we see that the anatomy of the disease is critical. In such cases, surgery is not performed simply to relieve symptoms, but to prevent a heart attack or sudden death.

3. As part of the Heart Team approach.

Today, the decision is not made by one doctor alone. A cardiologist and a cardiac surgeon assess the patient together. If we understand that surgery at an early stage can give a person another 15–20 years of active life without disability, we do not wait until medications stop helping.

So, surgery is not a “last chance”; it is a timely tool for restoring quality and length of life. Вставленный текст

— Many patients are afraid of the very phrase “you need heart surgery.” Does a recommendation for surgery always mean that the situation is already critical?

— Patients’ fear is completely understandable: in our culture, the heart is perceived as something almost untouchable. But in reality, a recommendation for surgery most often means the opposite — we are acting in time, before the situation becomes critical.

In modern cardiac surgery, there are two scenarios:

1. Emergency surgery.

This is when a catastrophe occurs, for example, an acute heart attack with complications or aortic dissection. In such cases, we really are saving a life immediately.

2. Elective surgery.

This accounts for the vast majority of operations. Here, our goal is to act proactively. We recommend intervention precisely when the heart still has a good reserve and the body can tolerate treatment well and recover quickly.

If we wait until the situation becomes “critical,” the risks of surgery increase significantly, while its potential benefit may be lower. Therefore, elective surgery is neither a sentence nor a last resort; it is a conscious step that protects against heart attack and disability and helps return a person to a full life. Вставленный текст

— Could you explain in simple terms which heart diseases most often require surgical treatment today?

— If we put complex terminology aside, surgical intervention is most often required for three types of conditions:

• Severe forms of coronary artery disease. When the coronary arteries are critically narrowed by plaques in several places and stenting is either no longer possible or is unlikely to provide a lasting result.
• Acquired or congenital heart valve defects. Primarily involving the aortic and mitral valves — stenosis or insufficiency that causes the heart to work under enormous strain.
• Aortic aneurysms and dissections. A bulging or separation of the wall of the body’s main blood vessel that requires reconstruction before critical complications occur.

In most cases, modern medicine allows these problems to be treated electively, restoring normal anatomy and extending life for decades. Вставленный текст

— One of the most common fears among patients is: “My heart will be stopped during the operation.” Does the heart really have to be stopped, and how does the body function during that time?

— The phrase “heart stoppage” frightens everyone, but in the operating room it is not a catastrophe; it is a high-tech pause.

While the surgeon carefully repairs a valve or blood vessel, a special heart-lung machine takes over the work of breathing and circulating the blood. The brain, kidneys, and all other organs continue to receive oxygen and nutrients while the heart is resting.

In some cases — for example, during bypass surgery — we work on a beating heart using special stabilizers.

So, stopping the heart during surgery is not about death; it is about creating ideal conditions to save the heart. Вставленный текст

— How dangerous is open-heart surgery today? What does surgical risk actually depend on?

— In short, today the risk of elective heart surgery is incomparably lower than the risk of living with an untreated disease.

Over the past 20–30 years, cardiac surgery has made tremendous progress. Whereas mortality and severe complications were previously measured in tens of percent, today the survival rate in elective surgery exceeds 98–99%.

What does the risk actually depend on? Patients often think that everything depends on how “difficult the operation is,” but surgical risk is determined by three key factors:

1. The status of the operation — elective versus emergency.

This is the main factor. If a patient comes for elective surgery — when the body is compensated, tests have been checked, and there is no acute heart failure — the risk is minimal, around 1–2%. If the patient is brought by ambulance with an acute catastrophe or in a state of shock, the risk increases several times over.

2. Associated diseases and overall health status.

We assess not only the heart but the entire body: kidney and lung function, the presence of diabetes, previous strokes, and the condition of the vessels in the neck and lower limbs. These underlying conditions often determine the complexity of the postoperative period.

3. Age and the body’s reserves.

Age itself is no longer considered a contraindication. We successfully operate on patients in their 70s and even over 80. However, we always assess what is known as frailty — the biological reserve of the tissues and organs.

For objective assessment, special scoring systems are used worldwide, such as EuroSCORE and STS Score. Dozens of patient parameters are entered, and the program calculates the mathematical percentage of risk.

Modern surgery is not guesswork; it is precise calculation. Вставленный текст

— A patient is offered surgery, but feels relatively well and decides to wait. How dangerous can such a decision be?

— The absence of symptoms is not necessarily a sign of good health; it may simply mean that the heart’s internal reserves are compensating for the disease. The heart can “endure” and adapt for a very long time.

Waiting is dangerous for three reasons:

• Heart cells can die silently. When symptoms finally appear, part of the heart muscle may already have turned into scar tissue that cannot be restored.
• Elective surgery can become emergency surgery. The risk of an elective procedure may be around 1%, while emergency surgery in the setting of a heart attack is much more dangerous.
• Time can be lost. The heart may become enlarged to such an extent that surgery is eventually too late.

“Proactive” surgery is a way of preserving a healthy heart rather than trying to restore what has already been destroyed. Вставленный текст

— Is there an age after which it is too late to perform heart surgery? For example, can patients aged 70–80 or older undergo successful surgery?

— Chronological age is simply a number. We operate not on a date of birth, but on a person’s biological status!

Today, patients aged 70, 80, and 85 successfully undergo heart surgery. The development of minimally invasive and tissue-sparing technologies has made it possible to perform procedures with minimal trauma and faster recovery.

If the heart and other organs retain sufficient functional reserve, we have no right to deny someone a better quality of life simply because of their age.

Heart surgery at the age of 80 today is not simply a risk; it is an opportunity to give a person another 10–15 years of active, happy life with their loved ones. Вставленный текст

— Regarding coronary artery disease: when is stenting sufficient, and when is coronary artery bypass grafting required?

— The choice between stenting, or percutaneous coronary intervention, and coronary artery bypass grafting is based on the anatomical complexity of the disease and the international SYNTAX Score.

• Stenting is preferable when the patient has isolated disease affecting one or two coronary arteries, short localized plaques, and a high surgical risk for open surgery.
• Coronary artery bypass grafting (CABG) is indicated when there is disease involving the left main coronary artery, three-vessel disease — especially when combined with diabetes or a reduced left ventricular ejection fraction — as well as diffuse calcification.

In complex cases, bypass surgery provides more complete myocardial revascularization and significantly reduces the need for repeat procedures in the future. Вставленный текст

— Patients often ask: “Why can’t you just place several stents instead of performing major surgery?” How is the decision made between stenting and bypass surgery?

— Imagine that you have an old water pipe that is rusty along its entire length.

You can put five patches — stents — on it. But a year later, it may start leaking somewhere else. Or you can install a new parallel plastic pipe — a bypass — once and forget about the problem for 20 years.

Placing four or five stents in a blocked vessel may mean that the patient has to return every few years for additional procedures because of recurrent blockages.

The decision is not made by one doctor alone, but by the Heart Team. We calculate the extent of vascular disease using the SYNTAX Score.

If the disease is extensive or the patient has diabetes, statistically, bypass surgery provides significantly more years of life without heart attacks than placing numerous stents. Вставленный текст

— In heart valve disease, when can a patient continue observation, and when is delaying surgery already dangerous?

— Management of valve disease is strictly guided by clinical and echocardiographic criteria.

• Dynamic observation is appropriate for moderate stenosis or insufficiency, or for severe borderline valve disease, if the patient has no clinical symptoms and the parameters of the left and right ventricles — including end-systolic dimensions and ejection fraction — as well as pulmonary artery pressure remain within normal limits.
• Indications for surgical treatment, including valve repair or replacement, include:

1. The appearance of significant symptoms such as shortness of breath, angina, or syncope.
2. An asymptomatic reduction in ejection fraction below 50% in aortic or mitral valve disease.
3. Progressive enlargement of the heart chambers — for mitral regurgitation, a left ventricular end-systolic diameter of ≥40 mm.
4. Newly developed atrial fibrillation or pulmonary hypertension.

Timely valve reconstruction or replacement prevents the development of irreversible myocardial dysfunction. Вставленный текст

— If a valve needs to be replaced, patients hear about mechanical and biological prosthetic valves. What is the difference, and how is the appropriate option chosen?

— What is the difference between a mechanical and a biological valve? It is essentially a choice between two approaches:

• Mechanical valve — once it is implanted, the need for repeat surgery is minimized. It is made from highly durable carbon material and can last for more than 50 years. However, the patient must take lifelong blood-thinning medication — anticoagulants.
• Biological valve — it reduces the need for long-term anticoagulant therapy. It is made from specially treated biological tissue. However, the valve lasts an average of 12–15 years, after which it may need to be replaced.

The basic formula for choosing is simple:

• Younger patients are more often given mechanical valves in order to avoid repeat surgery years later.
• Older patients (65+) are more often given biological valves because they can last longer relative to the patient’s expected lifespan, while the bleeding risk associated with blood-thinning medication becomes more important. Вставленный текст

— Does modern cardiac surgery necessarily involve a large incision in the chest? Which procedures can now be performed less invasively?

— A large sternotomy is no longer necessary in many cases! Modern cardiac surgery can be performed through a minimally invasive access measuring just 4–5 centimeters.

Through a small incision between the ribs, under video-camera guidance, we can successfully perform:

• Repair and replacement of the mitral and aortic valves;
• Coronary artery bypass surgery (MIDCAB);
• Removal of tumors and correction of congenital heart defects in adults.

The main advantage is that the breastbone remains intact. This means significantly less pain, no need for prolonged chest bracing, and the patient may be able to drive and return to normal life within 2–3 weeks. Вставленный текст

— Are there situations in which a person can live for years with a serious heart problem and have almost no symptoms?

— Yes! The heart is a remarkable silent worker. It will work extremely hard and adapt until the very last moment.

A person may live for years without realizing that they have three dangerous conditions:

• Aortic aneurysm — it may cause no pain at all until it reaches a critical size.
• Valve disease — the heart muscle simply pumps harder to compensate for the defect, while the person may only slow down slightly when walking and assume that they are simply “getting older.”
• Ischemia in people with diabetes — because of reduced nerve sensitivity, a person may experience minor heart attacks without a single episode of pain.

Remember: feeling well is not a guarantee of a healthy heart.

Some of the most dangerous diagnoses in cardiac surgery are often discovered during routine check-ups in people who came simply “to get checked.” Вставленный текст

— What symptoms should prompt a person to see a cardiologist as quickly as possible: shortness of breath, chest pain, swelling, irregular heartbeat, loss of consciousness?

— Remember the “red five” — symptoms for which delaying medical attention can be life-threatening:

1. Pressure-like or burning chest pain, especially if it radiates to the arm or jaw — a risk of heart attack. If it lasts more than 15 minutes, call an ambulance.

2. Shortness of breath with minimal walking or at night — this may signal valve disease or weakness of the heart muscle.

3. Loss of consciousness — this may indicate dangerous rhythm disturbances or valve stenosis.

4. Pauses or irregularities in the pulse — a manifestation of arrhythmia that can lead to stroke.

5. Swelling of the legs toward the evening — an indication that the heart is struggling to cope with the workload.

Each of these symptoms is your heart asking for help. Do not ignore it! Вставленный текст

— Is it true that after heart surgery a person has to severely restrict physical activity for the rest of their life?

— The main misconception is: “Heart surgery makes a person disabled.”

In reality, the opposite is true!

Before surgery, you lived with restrictions caused by the disease. Surgery removes those restrictions.

Restrictions are usually necessary only during the first 1.5–2 months, while the tissues heal. And after that? We do not simply allow movement — we actually encourage it!

Swimming, walking, cycling, sports, traveling, and active work can all become possible again.

The goal of modern cardiac surgery is not simply to give a person additional years of life, but to give them those years without shortness of breath, pain, and fear. Вставленный текст

— What mistakes do patients most often make after a successful operation?

— A successful operation is only half the journey. The main task afterward is to avoid four classic mistakes:

1. Stopping medications because “nothing hurts anymore.”

Stopping statins or blood-thinning medications without medical advice can lead to blockage of new bypass grafts and blood clots.

2. Returning to smoking.

Smoking after surgery can quickly damage even the most successful bypass grafts and blood vessels.

3. Going to extremes.

It is dangerous both to remain completely inactive and to start doing heavy physical work only one month after surgery. Physical activity should increase gradually.

4. Forgetting about heart ultrasound and laboratory tests.

Once a year, your “renewed” heart should be assessed by a specialist.

The surgeon gives the heart a new resource; your task is to protect it! Вставленный текст

— Can the disease return even after a technically perfect operation if a person does not change their lifestyle and does not take the prescribed medications?

— The short answer is: YES, the disease can return if the lifestyle is not changed.

A cardiac surgeon corrects the anatomy, but cannot eliminate atherosclerosis itself.

If, after an ideal bypass operation, a person returns to smoking, eats a fatty diet, and stops taking statins, new bypass grafts may become blocked by plaques within 2–3 years instead of lasting 20 years.

Surgery is not permanent immunity against disease; it is a second chance.

The surgeon gives you additional quality years of life, but how you use those years depends on you. Вставленный текст

— You work with the human heart every day, literally holding it in your hands. Has your profession changed your own attitude toward life and health?

— When you hold a human heart in your hands every day, you stop treating life as something eternal and guaranteed.

The most important thing surgery has taught me is that life is incredibly fragile, but at the same time remarkably resilient when we take care of the body.

I see blood vessels damaged by smoking and cholesterol, and I understand that our health is a daily choice.

I have learned to value time and my loved ones much more, and, of course, I try to set a personal example for my patients through physical activity, nutrition, and attention to my own body. Вставленный текст

— And the final question. If you could give people only one piece of advice that would help many of them never end up on an operating table, what would you say?

Modern cardiac surgery is capable of solving problems that seemed extremely difficult only a few decades ago. But the outcome of treatment depends not only on the surgeon and the technology.

One of the key factors is time.

The earlier a heart disease is detected, properly assessed, and the optimal treatment method is chosen, the greater the opportunity to preserve the patient’s heart function and quality of life.

Therefore, the main question should not only be:

“Is surgery frightening?”

It should also be:

“What will happen to my heart if I delay the surgery that I need?”