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Published on: March 27, 2018
Early Outcomes in Severely Obese Patients Undergoing Sternum-Sparing Minimally Invasive Multivessel Artery Bypass
Volodymyr Demianenko1, Markus Schlömicher1, Marius Grossmann1
1Department of Cardiothoracic Surgery, Heart-Thorax Center, Klinikum Fulda, University Medicine Marburg, Campus Fulda, Pacelliallee 4, 36043 Fulda, Germany.
Insights
Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT) is a safe and effective minimally invasive option for severely obese patients needing coronary artery bypass grafting (CABG). This sternum-sparing technique offers a valuable alternative, avoiding sternotomy complications for high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Obesity Medicine
Background:
- Severe obesity increases risks associated with traditional sternotomy for coronary artery bypass grafting (CABG).
- Patients with severe obesity are often excluded from less invasive, sternum-sparing surgical alternatives.
- This necessitates evaluating alternative surgical approaches for this patient demographic.
Purpose of the Study:
- To assess the safety and practicality of Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT).
- To evaluate TCRAT as a sternum-sparing option for severely obese patients requiring multivessel CABG.
- To compare outcomes of TCRAT in severely obese patients versus non-obese patients.
Main Methods:
- A cohort of 502 patients undergoing multivessel CABG via left anterior minithoracotomy was analyzed.
- 43 severely obese patients (BMI > 35.0 kg/m²) were compared to 459 non-obese patients (BMI < 35.0 kg/m²).
- Intraoperative variables (operative time, CPB, cross-clamp time) and postoperative outcomes (MACE, complications, length of stay) were evaluated.
Main Results:
- Severely obese patients had longer total operative times but comparable aortic cross-clamp and CPB times.
- Graft strategies and the number of distal anastomoses were similar between groups.
- No significant differences were found in major complications (mortality, stroke) or minor complications (wound healing, bleeding revisions).
- Intensive care unit and hospital lengths of stay were comparable between severely obese and non-obese patients.
Conclusions:
- Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT) is safe and effective for severely obese patients.
- TCRAT provides a feasible, minimally invasive option for complete revascularization in multivessel coronary artery disease.
- This sternum-sparing approach is a valuable surgical alternative for high-risk, severely obese patients undergoing CABG.
Abstract:
Background/Objectives: Severe obesity significantly increases the risk of complications following full sternotomy in coronary artery bypass grafting (CABG). However, these patients are frequently excluded from less invasive, sternum-sparing surgical alternatives. This study aimed to assess the safety and practicality of a newly developed technique-Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT)-that avoids sternotomy in patients with severe obesity requiring multivessel CABG. Methods: From November 2019 to May 2024, a total of 502 non-emergency patients with multivessel coronary artery disease underwent CABG through a left anterior minithoracotomy using cardiopulmonary bypass (CPB) and cardioplegic arrest. Of these, 43 patients with a body mass index (BMI) exceeding 35.0 kg/m2 were classified as severely obese and included for subgroup analysis. Their outcomes were compared to those of the remaining 459 patients with BMI below 35.0 kg/m2. Key intraoperative variables-such as total operative time, CPB duration, aortic cross-clamp time, and graft strategy-were evaluated. Postoperative outcomes, such as the incidence of major adverse cardiac and cerebrovascular events, minor complications, and length of stay in ICU and hospital, were also analyzed. Results: Severely obese patients exhibited a longer total operation time (353.5 ± 83.6 min vs. 320.4 ± 73.4 min, p < 0.05). In contrast, no statistical differences were observed in aortic cross-clamp time (97.9 ± 27.6 min vs. 95.6 ± 33.0 min; p = 0.307) or CPB time (163.3 ± 35.0 min vs. 155.0 ± 42.9 min; p = 0.078). Both groups received a similar number of distal anastomoses (3.1 ± 0.7 vs. 3.0 ± 0.8; p = 0.194), and the frequency of total arterial revascularization was comparable (34.9% vs. 40.0%; p = 0.268). There were no differences between the groups in major complications, including hospital mortality (2.3% vs. 1.1%, p = 0.227), stroke (0.0% vs. 0.6% p = 0.300), or need for re-revascularization (0.0% vs. 1.1%, p = 0.248). Similarly, minor complications, such as wound healing issues (2.3% vs. 1.1%, p = 0.233) and revisions for bleeding (4.6% vs. 7.2%, p = 0.276), were comparable between groups. ICU stay (2.7 ± 4.5 days vs. 2.2 ± 4.0 days; p = 0.225) and total hospital stay (12.3 ± 9.6 days vs. 10.8 ± 8.6 days; p = 0.142) showed no meaningful differences. Conclusions: TCRAT can be performed safely and effectively in severely obese patients, providing a feasible minimally invasive option for complete coronary revascularization in cases of multivessel disease. This approach eliminates the complications associated with sternotomy, making it a valuable surgical alternative for this high-risk patient group.
