What are the consequences of refusing to undergo open heart surgery?

Consequences of Refusing Open Heart Surgery

Refusing open heart surgery significantly increases the risk of mortality, cardiac death, heart failure, and overall deterioration of quality of life, particularly in patients with severe valvular heart disease.

Mortality and Cardiac Outcomes

• Patients with severe aortic stenosis who refuse cardiac surgery face approximately 10% mortality risk when undergoing even noncardiac procedures 1
• Natural history studies show that asymptomatic patients with severe mitral regurgitation who don't undergo surgery have a high likelihood of developing symptoms and/or left ventricular dysfunction within 6-10 years 1
• In one long-term study, patients with severe mitral regurgitation who did not undergo surgery had a 4% per year risk of cardiac death 1
• A documented case showed cardiac death in a patient who refused surgery despite having indications (left ventricular dilation) for the procedure 1

Disease-Specific Consequences

Valvular Heart Disease

• Aortic Stenosis:

  • Severe symptomatic aortic stenosis left untreated leads to progressive heart failure and increased mortality 1
  • Patients who refuse aortic valve replacement despite severe stenosis face substantially higher perioperative risks during any future surgeries 1

• Mitral Regurgitation:

  • Refusing surgery for severe mitral regurgitation leads to:
    • Progressive left ventricular dilation and dysfunction 1
    • Development of atrial fibrillation, which independently increases risk of cardiac death or heart failure 1
    • Potential for irreversible cardiac damage, reducing the success of future interventions 1

Heart Failure Progression

• Heart failure patients who refuse surgical intervention face:
  • Substantially higher risks of operative mortality and hospital readmission compared to other patients, including those with coronary disease 2
  • In emergency surgical situations, heart failure patients have 13.7% 30-day mortality, 22.4% 90-day mortality, and 39.3% 1-year mortality 3
  • Even in ambulatory surgical settings, heart failure patients have significantly higher 90-day mortality (2% vs 0.39%) compared to those without heart failure 4

Complications from Delayed Intervention

• Delaying necessary valve surgery can lead to:

  • Development of irreversible left ventricular dysfunction 1
  • Onset of atrial fibrillation, which is associated with increased mortality and thromboembolism risk 1
  • Persistence of atrial fibrillation after eventual surgery if delayed too long (80% persistence rate if atrial fibrillation present ≥3 months before surgery) 1

• Refusing surgery when indicated may result in:

  • Need for emergency rather than elective procedures, with significantly higher mortality rates 3
  • Progression to more complex surgical needs with higher operative risks 1
  • Development of pulmonary hypertension, which further complicates surgical outcomes 1

Special Considerations

• For asymptomatic patients with severe mitral regurgitation and normal left ventricular function:

  • Refusing surgery means accepting a high likelihood of developing symptoms or left ventricular dysfunction within 6-10 years 1
  • Development of atrial fibrillation significantly increases mortality risk 1

• For patients with heart failure:

  • Refusing surgical intervention results in significantly higher mortality even for non-cardiac procedures 2, 3, 4
  • Both symptomatic and asymptomatic heart failure patients have increased mortality risk when refusing indicated surgery (3.57% and 1.85% respectively vs 0.39% in non-heart failure patients) 4

Risk Mitigation for Those Refusing Surgery

• For patients who absolutely refuse cardiac surgery:
  • Consider less invasive alternatives when appropriate (e.g., percutaneous balloon aortic valvuloplasty as a bridge in hemodynamically unstable patients) 1
  • Implement aggressive medical therapy, including beta blockers and cardiac resynchronization therapy when appropriate 1
  • Ensure strict endocarditis prophylaxis in all patients with significant valve disease 1
  • Maintain optimal anticoagulation in patients with atrial fibrillation 1