Is full CABG with complete revascularization preferred over minimally invasive CABG for a patient with complex coronary artery disease and controlled hypothyroidism?

Full CABG with Complete Revascularization is Mandatory for This Patient

This 47-year-old patient with complex three-vessel disease (LAD 90%, D1 99%, D2 90%, LCX CTO, RCA 70-80% sequential lesions) requires full CABG with complete revascularization, not minimally invasive single-vessel surgery. The proposed minimally invasive LIMA-LAD approach that leaves the LCX and RCA ungrafted is inadequate and contradicts current evidence-based guidelines. 1, 2

Why Complete Revascularization is Required

The 2024 ESC Guidelines provide Class I, Level A evidence that CABG is recommended for patients with three-vessel disease and preserved LVEF to improve symptoms, survival, and other outcomes. 1 This patient has:

• Three-vessel disease with high anatomical complexity (proximal-mid LAD 90%, D1 99%, D2 90%, LCX CTO, RCA sequential 70-80% lesions) 1
• Preserved left ventricular function (normal EF, no wall motion abnormalities) 1
• Multiple high-risk features: diabetes (DLP), smoking, hypertension, hypothyroidism 1

Complete revascularization during CABG is independently associated with significant reduction in major adverse cardiac and cerebrovascular events (HR 0.82,95% CI 0.70-0.95, P=0.01), with 5-year freedom from MACE of 72.5% versus 66.7% for incomplete revascularization. 3

The Minimally Invasive Approach is Inadequate

Leaving the LCX CTO and RCA sequential lesions ungrafted constitutes incomplete revascularization and will result in:

• Higher rates of residual angina (22.8% vs 9.9% with complete revascularization) 4
• Increased need for repeat revascularization (17.5% vs 7.0%) 4
• Worse long-term survival and MACE outcomes 3

The ESC guidelines specifically recommend complete revascularization for multivessel disease, taking into account the likelihood of achieving revascularization completeness as a key decision factor. 1

Addressing the Hypothyroidism Concern

The surgeon's claim that controlled hypothyroidism necessitates avoiding full CABG due to prolonged intubation/delayed extubation is not supported by current guidelines and represents a relative, not absolute, contraindication. 1

• This patient has CONTROLLED hypothyroidism on medication (presumably levothyroxine)
• No guideline identifies controlled hypothyroidism as a contraindication to full sternotomy CABG 1, 2
• The patient is 47 years old with normal LV function and no other surgical contraindications mentioned 1

If hypothyroidism were truly uncontrolled, the appropriate response would be to optimize thyroid function preoperatively, not to perform inadequate revascularization. 1

Recommended Surgical Strategy

Full sternotomy CABG with the following grafts:

1. LIMA to LAD (Class I recommendation, >90% patency at 10 years) 2
2. Radial artery or saphenous vein graft to RCA territory (addressing the 70-80% sequential lesions) 2
3. Grafting to diagonal branches (D1 99%, D2 90% require revascularization) 1, 3
4. Consideration of grafting to LCX territory despite CTO, as collaterals from LAD indicate viable myocardium 5, 6

The ESC recommends using a Heart Team approach to select the most appropriate revascularization modality based on patient profile, coronary anatomy, procedural factors, LVEF, preferences, and outcome expectations—but in this case, the anatomy clearly mandates complete surgical revascularization. 1

Critical Pitfalls to Avoid

• Do not accept incomplete revascularization based on surgical convenience or unfounded concerns about controlled comorbidities 3
• Do not allow minimally invasive technique preference to compromise completeness of revascularization 5, 6
• Ensure preoperative thyroid function is optimized (TSH, free T4 levels checked) but do not use controlled hypothyroidism as justification for inadequate surgery 1
• Document that patient and family understand the superiority of complete revascularization for long-term outcomes 3, 4

If the surgeon is unwilling to perform full CABG, seek a second surgical opinion from another cardiac surgeon who can perform complete revascularization via standard sternotomy. 1, 2