Early Outcomes in Severely Obese Patients Undergoing Sternum-Sparing Minimally Invasive Multivessel Artery Bypass Grafting Using Total Coronary Revascularization via Left Anterior Mini-Thoracotomy

<b>Background/Objectives:</b> 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. <b>Methods</b><i>:</i> 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. <b>Results</b>: Severely obese patients exhibited a longer total operation time (353.5 ± 83.6 min vs. 320.4 ± 73.4 min, <i>p</i> < 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; <i>p</i> = 0.307) or CPB time (163.3 ± 35.0 min vs. 155.0 ± 42.9 min; <i>p</i> = 0.078). Both groups received a similar number of distal anastomoses (3.1 ± 0.7 vs. 3.0 ± 0.8; <i>p</i> = 0.194), and the frequency of total arterial revascularization was comparable (34.9% vs. 40.0%; <i>p</i> = 0.268). There were no differences between the groups in major complications, including hospital mortality (2.3% vs. 1.1%, <i>p</i> = 0.227), stroke (0.0% vs. 0.6% <i>p</i> = 0.300), or need for re-revascularization (0.0% vs. 1.1%, <i>p</i> = 0.248). Similarly, minor complications, such as wound healing issues (2.3% vs. 1.1%, <i>p</i> = 0.233) and revisions for bleeding (4.6% vs. 7.2%, <i>p</i> = 0.276), were comparable between groups. ICU stay (2.7 ± 4.5 days vs. 2.2 ± 4.0 days; <i>p</i> = 0.225) and total hospital stay (12.3 ± 9.6 days vs. 10.8 ± 8.6 days; <i>p</i> = 0.142) showed no meaningful differences. <b>Conclusions</b>: 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.