Minimally Invasive Total Arterial Bypass Grafting via Left Mini-thoracotomy in Obese Patients

Ibrahim Gadelkarim; Rakan Shaqu; Jagdip Kang; Waseem Zakhary; Alexey Dashkevich; Jörg Ender; Sussane de Waha; Michael Borger; Alexander Verevkin

doi:10.1055/a-2668-4842

The Thoracic and Cardiovascular Surgeon, Table of Contents

Thorac Cardiovasc Surg
DOI: 10.1055/a-2668-4842

Original Cardiovascular

Minimally Invasive Total Arterial Bypass Grafting via Left Mini-thoracotomy in Obese Patients

Authors

Ibrahim Gadelkarim^*

¹Department of Herzchirurgie, Herzzentrum Leipzig Universitatsklinik, Leipzig, Sachsen, Germany
Rakan Shaqu^*

²Department of Cardiac Surgery, Herzzentrum Leipzig Universitatsklinik, Leipzig, Deutschland, Leipzig, Germany
Jagdip Kang

³Leipzig Heart Centre University Hospital, Leipzig, Germany
Waseem Zakhary

⁴Department of Anaesthesiology, Universität Leipzig Herzzentrum, Leipzig, SN, Germany
Alexey Dashkevich

¹Department of Herzchirurgie, Herzzentrum Leipzig Universitatsklinik, Leipzig, Sachsen, Germany
Jörg Ender

⁵Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, Leipzig Heart Centre University Hospital, Leipzig, Sachsen, Germany
Sussane de Waha

⁶Department of Rhythmology, University Hospital Schleswig-Holstein Lübeck Campus, Lübeck, SH, Germany
Michael Borger

⁷Herzzentrum Leipzig, Leipzig, Germany
Alexander Verevkin

⁸Department of Cardiac Surgery, Leipzig Heart Centre University Hospital, Leipzig, Sachsen, Germany

Abstract

All articles of this category

Abstract

Background

Minimally invasive cardiac surgery total arterial coronary artery bypass grafting (MICS-CABG) has emerged as an alternative to conventional coronary artery bypass grafting (CABG). Its safety and efficacy in obese patients remain a concern due to technical challenges. The current study compares early and long-term outcomes of MICS-CABG in obese and non-obese patients.

Methods

Between January 2015 and December 2023, 279 patients underwent off-pump MICS-CABG at our center. Obesity was defined as body mass index ≥30 (kg/m²). The primary endpoint was 30-day survival. Secondary endpoints were survival and freedom from major adverse cardiac and cerebrovascular events (MACCE) at 5 years.

Results

Of all 279 patients, 56 (20.1%) were classified as obese and 223 (79.9%) as non-obese. Obese patients had a higher EuroSCORE II (2.06 ± 1.53 vs. 1.63 ± 0.94, p = 0.008) and a higher prevalence of comorbidities including diabetes mellitus (p < 0.001) and pulmonary hypertension (p = 0.03). The incidence of postoperative complications including repeat thoracotomy for bleeding (p = 0.18), low cardiac output syndrome (p = 0.70), or wound infection (p = 0.38) did not differ between obese and non-obese patients. There were no deaths or myocardial infarctions within 30 days in obese patients (0% vs. 0.5%, p = 0.95; 0% vs. 2.7%, p = 0.47). Long-term outcome at 5 years, including survival (91.9% vs. 92.4%, p = 0.99) and freedom from MACCE (83.3% vs. 84.6%, p = 0.63), showed no difference between the two groups.

Conclusion

MICS-CABG can be performed safely and efficaciously in select obese patients by specialized coronary surgeons at high-volume cardiac centers.

Keywords

minimally invasive surgery (includes port access mini-thoracotomy) - coronary artery bypass grafts surgery - CABG - obesity

Full Text

References

References
1 Kluge HHP. Weltgesundheitsorganisation, editors. WHO European Regional Obesity Report 2022. Copenhagen: World Health Organization; 2022: 1
2 Marques A, Peralta M, Naia A, Loureiro N, de Matos MG. Prevalence of adult overweight and obesity in 20 European countries, 2014. Eur J Public Health 2018; 28 (02) 295-300
3 Eid O, Eid R, Styliou T. et al. Prevalence and impact of high BMI in CAD patients. Eur J Prev Cardiol 2022; 29 (Suppl. 01) zwac056.179
4 Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001; 20 (06) 1168-1175
5 Taggart DP, Gaudino MF, Gerry S. et al; ART investigators. Effect of total arterial grafting in the Arterial Revascularization Trial. J Thorac Cardiovasc Surg 2022; 163 (03) 1002-1009.e6
6 Urso S, Sadaba R, González JM. et al. Total arterial revascularization strategies: a meta-analysis of propensity score-matched observational studies. J Card Surg 2019; 34 (09) 837-845
7 Navia D, Vrancic M, Vaccarino G. et al. Total arterial off-pump coronary revascularization using bilateral internal thoracic arteries in triple-vessel disease: surgical technique and clinical outcomes. Ann Thorac Surg 2008; 86 (02) 524-530
8 Davierwala PM, Leontyev S, Garbade J. et al. Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience. Ann Cardiothorac Surg 2018; 7 (04) 483-491
9 Sakaguchi T, Totsugawa T, Tamura K. et al. Minimally invasive coronary artery bypass grafting: useful routine option for coronary revascularization in selected cases. Gen Thorac Cardiovasc Surg 2020; 68 (10) 1128-1133
10 McGinn Jr JT, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation 2009; 120 (11, Suppl): S78-S84
11 Teman NR, Hawkins RB, Charles EJ. et al; Investigators for the Virginia Cardiac Services Quality Initiative. Minimally invasive vs open coronary surgery: a multi-institutional analysis of cost and outcomes. Ann Thorac Surg 2021; 111 (05) 1478-1484
12 Ziankou A, Ostrovsky Y. Early and midterm results of no-touch aorta multivessel small thoracotomy coronary artery bypass grafting: a propensity score-matched study. Innovations (Phila) 2015; 10 (04) 258-267 , discussion 267
13 Ruel M, Shariff MA, Lapierre H. et al. Results of the minimally invasive coronary artery bypass grafting angiographic patency study. J Thorac Cardiovasc Surg 2014; 147 (01) 203-208
14 Fatehi Hassanabad A, Kang J, Maitland A, Adams C, Kent WDT. Review of contemporary techniques for minimally invasive coronary revascularization. Innovations (Phila) 2021; 16 (03) 231-243
15 Davierwala PM, Verevkin A, Sgouropoulou S. et al. Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: early outcomes and angiographic patency. J Thorac Cardiovasc Surg 2021; 162 (04) 1109-1119.e4
16 Verevkin A, Von Aspern K, Tolboom H. et al. Total arterial multivessel minimally invasive coronary artery bypass surgery: 5-year outcomes. Ann Thorac Surg 2024; 118 (05) 1044-1051
17 Bayer N, Hart WM, Arulampalam T, Hamilton C, Schmoeckel M. Is the use of BIMA in CABG sub-optimal? A review of the current clinical and economic evidence including innovative approaches to the management of mediastinitis. Ann Thorac Cardiovasc Surg 2020; 26 (05) 229-239
18 Kayatta MO, Halkos ME, Puskas JD. Hybrid coronary revascularization for the treatment of multivessel coronary artery disease. Ann Cardiothorac Surg 2018; 7 (04) 500-505
19 Serruys PW, Morice MC, Kappetein AP. et al; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360 (10) 961-972
20 Thygesen K, Alpert JS, Jaffe AS. et al; Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J 2012; 33 (20) 2551-2567
21 Dietze Z, Marín-Cuartas M, De La Cuesta M, Dashkevich A, Borger MA, Verevkin A. Anaortic total arterial minimally invasive coronary artery bypass grafting: the Leipzig technique. Multimed Man Cardiothorac Surg 2025; 2025: 2025
22 Liu JJ, Liang L, Kong QY, Ma XL, Chi LQ, Lai YQ. A study on the perioperative effects of obesity on minimally invasive coronary artery bypass grafting and its surgical techniques. Interdiscip Cardiovasc Thorac Surg 2023; 36 (06) ivad092
23 Lazar HL. The risk of mediastinitis and deep sternal wound infections with single and bilateral, pedicled and skeletonized internal thoracic arteries. Ann Cardiothorac Surg 2018; 7 (05) 663-672