Comparative results of pulmonary vein isolation in atrial fibrillation patients undergoing off-pump vs. on-pump beating-heart coronary artery bypass grafting: a retrospective cohort study

Introduction

According to the Global Burden of Disease Index, coronary artery disease (CAD) was the second leading cause of death across all age groups in 2019 (1). Coronary artery bypass grafting (CABG) remains the most common cardiac surgical intervention, while the global prevalence of atrial fibrillation (AF) continues to rise (2). As a result, the proportion of patients who present with AF and CAD is increasing (3), which raises the risk of heart failure and stroke and will have a significant negative economic impact on our healthcare system. Early mortality following CABG is 64% more common in patients with pre-existing AF, according to a meta-analysis and systematic review of 13 trials including more than 300,000 participants (4).

The current indication and evidence class for concomitant surgical ablation in patients undergoing coronary artery grafting is set significantly lower compared to those undergoing mitral surgery (IIa-B vs. I-A) (2). This is probably because there were fewer case series and publications on AF and CABG at the time when the AF task force wrote the guidelines. Nevertheless, the LAAOS III study (5) has led to the classification of the indication for concomitant surgical left atrial appendage occlusion (LAAO) as class I-B (2).

Since 2010, all surgeons at our centre have routinely performed off-pump coronary artery bypass (OPCAB) surgery using bilateral internal thoracic arteries in a high majority of cases (>90%) (6). Since 2020, we have revised our AF program to implement a more rigorous screening process for patients presenting for cardiac surgery with pathologies beyond atrio-ventricular valve issues. Not wishing to abandon our highly effective OPCAB program, we have considered options to maintain the OPCAB revascularization strategy, while incorporating a robust concomitant AF approach. Therefore, we made the decision to combine the revascularisation procedure with pulmonary vein isolation (PVI) using a radiofrequency bipolar clamp in cases of isolated coronary artery revascularisation. This is followed by control and confirmation that a bidirectional block has been accomplished.

Fortunately, there is an increasing body of evidence regarding long-term benefits of freedom from AF and stroke-free survival with combined surgical ablation and left atrial appendage closure in CABG patients (7-10). Nevertheless, surgical management of AF in the context of coronary revascularization remains technically demanding, particularly during off-pump or on-pump beating-heart procedures. The limited exposure of the left atrium, the absence of cardioplegic arrest, and the need to maintain hemodynamic stability make epicardial PVI more complex compared to ablation performed under cardioplegic conditions. Consequently, the available evidence on rhythm outcomes after concomitant ablation in these settings is scarce (11), and most published studies are small, single-centre experiences.

The objective of the study was to examine the safety and efficacy of PVI and LAAO in the context of OPCAB or on-pump beating heart CABG among patients treated in our institution. The secondary objectives included the conversion rate to sinus rhythm (SR) during follow-up with or without continued antiarrhythmic drugs (AAD) classes I or III, the survival rate, and the incidence rate of major adverse cardiac and cerebrovascular events (MACCE) in mid-term follow-up. We present this article in accordance with the STROBE reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-464/rc).

Methods

Study design

This was a retrospective single-centre cohort study conducted at the Department of Cardiovascular Surgery, Robert Bosch Hospital (Stuttgart, Germany). The analysis included consecutive patients with preoperative AF who underwent CABG combined with epicardial PVI and LAAO between December 2021 and November 2024. Patients undergoing emergency procedures, concomitant valve or aortic surgery, or reoperations for non-ischemic indications were excluded. Participation in the study was unaffected by pre- and perioperative risk factors and was not contingent upon the preoperative probability of AF recurrence and it was entirely voluntary.

The ethics committee of the Medical University Tübingen examined and approved the study proposal, which adhered to the principles specified in the Declaration of Helsinki and its subsequent amendments (ethics registration No. 776/2021B02 dated December 6, 2021). Before their participation in the research, all subjects provided their written informed consent.

AF management

In our institutional practice, all isolated CABG procedures are primarily planned as off-pump operations. Conversion to on-pump beating-heart CABG is reserved for cases with intraoperative hemodynamic instability or limited exposure of target coronary vessels.

Regardless of whether the patient exhibited paroxysmal, persistent, or long-standing persistent AF (persAF), all patients received bilateral PVI using a bipolar radiofrequency clamp, Isolator Synergy™ Ablation Clamp (AtriCure, Inc., Mason, OH, USA). Since the PVI requires manipulation that could tear the in-place bypasses, we often conducted the ablation after graft harvesting and before starting with the myocardial revascularisation. The sequence of the surgical steps is ultimately determined by the lead surgeon. One surgeon prefers to first place the left internal thoracic artery to the left anterior descending coronary bypass, particularly in cases of left main stenosis, and then proceeds with the PVI. Upon completion of the bilateral PVI, we proceeded to test with an Isolator PenÔ (AtriCure, Inc., Mason, OH, USA) to determine whether a bidirectional conduction block had been successfully achieved. Before testing the conduction block, if the patient was in AF, we first performed an internal electrical cardioversion. If the block was not complete, we would run extra lines until the bidirectional conduction block was completed. When additional lines were applied, these were performed directly over the initial PVI lines to reinforce lesion continuity and transmurality. No supplementary mitral or tricuspid lines were created. The remainder of the procedure is carried out in a standardised fashion (6). Regarding the LAAO, the surgeons’ choice of technique and device is contingent upon the intended graft placement approach. In off-pump procedures, LAAO was preferentially performed using a clip device. Care was taken in patients with a T-graft configuration of the internal thoracic arteries to ensure that the right internal thoracic artery did not run directly beneath the LAA, thereby avoiding contact with the clip and potential inflammatory interaction.

Following surgery, we implemented a structured AF protocol for both the in-hospital phase and the initial months post-surgery, which we have previously published in an extended version (12). We advise the performance of Holter electrocardiogram (EKG) and echocardiogram at 6 months, 12 months, and subsequently on an annual basis (12).

Patients were contacted in writing, and if they could not be reached then again by telephone, and were asked to provide the results of their last cardiologist check-up, specifically the EKG or Holter EKG, preferably the last echocardiogram, and their most recent medication. The survey also included questions about whether participants had experienced palpitations, as well as any documented occurrences of AF or other arrhythmias during the blanking period or outside of it. Additionally, if an incident occurred, questions about the treatment being received were also raised. The questionnaire also featured enquiries regarding significant end-points, specifically those related to MACCEs, such as the occurrence of stroke, acute myocardial infarction, or mortality during the follow-up period.

In accordance with current guideline recommendations (2), arrhythmia recurrence was defined as any documented episode of AF, atrial flutter, or atrial tachycardia lasting ≥30 seconds. Postoperative rhythm monitoring included continuous telemetry during hospitalization, followed by scheduled 12-lead ECGs and 24-hour Holter recordings during outpatient follow-up. However, the follow-up rhythm assessments were performed at discrete time points, rather than continuous monitoring. Consequently, the exact timing of AF recurrence was not uniformly available, and time-dependent survival curves for arrhythmia recurrence could not be reliably generated.

The primary efficacy endpoints were SR maintenance with or without AADs and overall survival (OS). Secondary endpoints included freedom from MACCE (death, stroke, or myocardial infarction), anticoagulation status at follow-up, and perioperative complications as measures of procedural safety.

Bias management

This was a retrospective, nonrandomized analysis that may be subject to selection and information bias. These were minimized by including all consecutive eligible patients within the defined study period and by achieving complete follow-up for all cases. No patients were lost to follow-up, and data accuracy was verified by cross-checking institutional surgical and follow-up records.

Statistical analysis

As this was a retrospective, consecutive cohort including all eligible patients treated within the study period, no a priori sample size or power calculation was performed. Categorical data are presented as absolute numbers and percentages, while continuous data are expressed as mean ± standard deviation (SD) if normally distributed or as median and interquartile range (IQR) if non-normal distributed. The following statistical methods were used for data comparison: Chi-squared test (χ² test) for binary data, Wilcoxon-Mann-Whitney U test for nonparametric data, t-test assuming a normal distribution. No correlation analyses between continuous variables were performed, as the study aimed primarily to compare clinical and rhythm outcomes between the two groups. Differences were deemed statistically significant when the P value was less than 0.05, and all statistical tests were two-sided. The patient’s survival rates were estimated using Kaplan-Meier curves. The log-rank test was implemented to ascertain the distinctions between the categories. Data analysis was conducted using SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, New York, USA). Tables were created using Microsoft Excel 2021 for Windows (Microsoft Corp., Redmond, WA, USA).

Results

Patients in the on-pump beating-heart cohort were marginally younger (68.47±6.79 vs. 71.19±7.59 years) but demonstrated a more elevated risk profile, characterised by increased BMI (30.55±6.21 vs. 28.92±4.57 kg/m²), higher median European system for cardiac operative risk evaluation (EuroSCORE II) (4.47 vs. 3.31), elevated creatinine levels at presentation (1.52±1.84 vs. 1.05±0.35 mg/dL), and a greater proportion of individuals with medically managed diabetes, both with oral antidiabetic agents and insulin. Additionally, there was a higher prevalence of patients with a positive history of chronic obstructive pulmonary disease (3 vs. 0) and a greater percentage of patients exhibiting a left ventricular ejection fraction below 30% (3 vs. 1). Nevertheless, none of these indicators attained statistical significance between the two groups. Only one entity was notable: neurological disease, in which patients in the on-pump beating-heart group exhibited a significantly higher percentage of transient ischaemic attacks (TIA) or cerebrovascular attacks (CVA) with residual deficits (7 vs. 1), likely attributable to AF. The comprehensive baseline and demographic data of the two groups are displayed in Table 1.

Table 2 focuses on the AF characteristics and previous medication, specifically prior anticoagulant treatment upon presentation, between the two groups. The off-pump group predominantly comprised patients with paroxysmal AF (PAF), whereas the on-pump beating-heart group was primarily composed of patients with persAF or long-standing persAF (lspersAF). This explains the prolonged AF duration in the on-pump beating-heart cohort. Regarding the oral anticoagulant (OAC) therapy at presentation in both groups, apixaban and rivaroxaban were the most prevalent.

Detailed echocardiographic data on left atrial dimensions were not consistently available, precluding reliable analysis of atrial size. With respect to mitral valve pathology, no patient exhibited more than moderate insufficiency. Eighteen patients had first-degree and nine patients second-degree mitral valve insufficiency, distributed similarly between groups (off-pump: 10 and 5; on-pump beating-heart: 8 and 4, respectively). These findings reflect the overall low prevalence of significant valvular disease in the cohort.

Except for one patient who received a box lesion, all other patients underwent PVI. Regarding the left atrial appendage, two patients did not receive any LAA intervention. The intensive care unit duration and hospital stay were somewhat higher in the on-pump beating-heart group. One patient in the off-pump group required emergency rethoracotomy for left-sided hemothorax on day 5 after surgery. The event was not related to the CABG or PVI procedure. There were no recorded CVAs, low cardiac output, acute myocardial infarctions, or deaths in the first 30 days after surgery. The particulars are illustrated in Table 3.

The in-hospital data related to AF presented in Table 4 reveal several key findings: one pacemaker was implanted due to the development of sick sinus syndrome postoperatively, 36.3% of the entire cohort of 44 patients received amiodarone treatment, and a significantly higher percentage of patients in the off-pump group were discharged with SR compared to those in the on-pump beating-heart group.

The follow-up quote was 100%. During follow-up, 14 patients experienced arrhythmia recurrence, including 9 cases of PAF, 3 of persAF, and 2 cases of typical atrial flutter (Table 5). However, because the follow-up was conducted more than a year after the procedure, the patients were unable to appropriately attribute this occurrence to the inside or outside of the blanking period. Rhythm management was conservative in 8 patients, medical therapy with amiodarone was initiated in 3 patients, and electrical cardioversion was performed in 2 patients. One patient with typical atrial flutter underwent successful catheter ablation. In our institutional practice, any organized atrial tachyarrhythmia recurrence after surgical PVI is evaluated by electrophysiology specialist for potential targeted ablation.

During the follow-up period, no strokes or myocardial infarctions were observed (Table 5); thus, OS and MACCE-free survival were identical. Both off-pump and on-pump beating-heart groups demonstrated excellent event-free survival, with 92% and 94%, respectively, at a median follow-up of two years. No statistically significant differences were observed between groups (log-rank test P value 0.84). Figure 1 depicts the Kaplan-Meier survival analysis for the two groups.

Figure 1 Kaplan-Meier survival curves for the two groups.

The follow-up echocardiograms lacked relevant information concerning the LAA. Only 18.2% of the entire population was off oral anticoagulation. These patients had a mean CHA₂DS₂-VASc score of 4.1 compared with 3.7 in those remaining on therapy. Sinus-rhythm maintenance without AADs was more frequent among patients off OAC (88% vs. 69%), whereas rates of LAAO and AF type distribution were similar. This suggests that the decision to discontinue anticoagulation was primarily guided by sustained SR rather than by baseline risk or procedural factors.

The most important finding is the significant proportion of patients in SR observed at follow-up with or without the use of oral AADs.

Amiodarone was the only AAD administered in this cohort. At baseline, 18% of patients received AAD therapy, increasing to 36% at hospital discharge and decreasing to 9% at follow-up. Among those who discontinued amiodarone, 80% remained in stable SR without antiarrhythmic medication, while 50% of those still on amiodarone maintained SR. These data indicate that AAD discontinuation was primarily driven by sustained rhythm stability.

The SR rate in the off-pump group was 77.7% without the use of AAD and 81.4% with their administration (Figure 2). The analysis of the on-pump beating-heart group revealed an SR rate of 64.7% without AAD and 70.5% with AAD (Figure 3).

Figure 2 SR conversion rate with or without AADs for the off-pump study group, classified by type of AF and overall. AAD, antiarrhythmic drugs; AF, atrial fibrillation; lspersAF, long-standing persistent atrial fibrillation; PAF, paroxysmal atrial fibrillation; persAF, persistent atrial fibrillation; SR, sinus rhythm.

Figure 3 SR conversion rate with or without AADs for the on-pump beating-heart study group, classified by type of AF and overall. AAD, antiarrhythmic drugs; AF, atrial fibrillation; lspersAF, long-standing persistent atrial fibrillation; PAF, paroxysmal atrial fibrillation; persAF, persistent atrial fibrillation; SR, sinus rhythm.

When looking at the entire study population, 76.9% of individuals initially presenting with PAF, as well as 66.6% of those with persistent or lspersAF, were in SR without AAD at follow-up, and with AAD those percentages were 80.7% and 72.2%, respectively (Figure 4).

Figure 4 SR conversion rate with or without AADs for the entire study group, classified by type of AF and overall. AAD, antiarrhythmic drugs; AF, atrial fibrillation; lspersAF, long-standing persistent atrial fibrillation; PAF, paroxysmal atrial fibrillation; persAF, persistent atrial fibrillation; SR, sinus rhythm.

To illustrate the relationship between AF chronicity and rhythm outcome, the distribution of SR maintenance according to AF duration is shown in Table 6. Due to the small subgroup sizes, these data are presented descriptively without statistical comparison.

To assess whether baseline operative risk influenced rhythm and survival outcomes, patients were stratified according to EuroSCORE II into four clinically meaningful categories: very low risk (<1%), low risk (1–2.99%), moderate risk (3–4.99%), and high risk (≥5%). SR maintenance without antiarrhythmic therapy was 75% in the low-risk group, 85% in the moderate-risk group, and 64% among high-risk patients, with a corresponding increase in mortality from 0 to 14%. Within each risk stratum, rhythm outcomes were comparable between off-pump and on-pump beating-heart CABG, although off-pump procedures consistently showed numerically higher SR rates. These findings indicate that higher baseline surgical risk may modestly reduce rhythm success and survival but does not significantly alter the relative benefit of concomitant PVI (Table 7).

Discussion

This single-centre retrospective observational study demonstrated that performing PVI and LAAO concurrently with CABG, using either off- or on-pump beating-heart revascularisation, was a safe and effective method for restoring SR. The hospital stay for both groups was largely uneventful, with no fatalities within 30 days and no significant adverse cardiac or cerebrovascular events. The conversion rate to SR in both groups was commendable, achieving 81.4% in the off-pump group, with or without antiarrhythmics, and 70.5% in the on-pump beating-heart group, resulting in an overall rate of 77.2% for the entire study cohort.

Previous studies have consistently shown that the presence of untreated preoperative AF adversely affects outcomes after CABG, with higher postoperative mortality and morbidity compared to patients in SR (7-10,13). Several large registry and meta-analytic reports comprising more than half a million patients have confirmed these trends, underscoring the prognostic impact of AF in surgical revascularization cohorts (7-10). However, most of these analyses evaluated heterogeneous CABG populations and did not provide specific information on whether or how AF ablation or left atrial appendage management was performed (7-9). In contrast, our study focuses exclusively on patients undergoing concomitant PVI during off-pump or on-pump beating-heart CABG, offering a more homogeneous and procedure-specific perspective. Despite differences in surgical setting and ablation techniques, the rhythm maintenance and survival outcomes observed in our cohort are broadly consistent with the favorable results reported in contemporary series addressing concomitant surgical ablation (7-9), while confirming that such interventions can be safely applied even in off-pump or beating-heart contexts.

Pokushalov et al. randomised 35 PAF patients to CABG alone or with epicardial PVI. Following surgery, 16 (89%) patients in the CABG + PVI group were AF-free at 18 months, compared to 8 (47%) in the CABG only group (log-rank test, P=0.007) (14). A prior study by the same working group examined 72 PAF patients who received epicardial PVI with bipolar radiofrequency during CABG. A total of 72% were AF-free without antiarrhythmics 12 months after surgery (15). Both investigations reported performing the PVI method on-pump beating-heart and confirming a bidirectional conduction block. Similar to Pokushalov et al. (14,15), our PAF on-pump beating-heart group had 87.5% SR without AAD at follow-up.

Cherniavsky et al. randomised 95 patients with persAF and CAD to open-heart surgery with intraoperative irrigated radiofrequency ablation: CABG + PVI, n=31; CABG + minimally invasive MAZE procedure (miniMAZE), n=30; and isolated CABG, n=34 (16). They reported similar low relapse rates. Loop recorders showed 80% freedom from AF in the CABG + PVI group, 86.2% in the CABG + miniMAZE group, and 44.1% in the CABG alone group at 14 months (16). Our group of patients who had persistent and long-standing AF converted to SR at 72.2%, comparable to Cherniavsky et al.’s CABG + PVI group.

Nisivaco et al. hypothesise in an expert review that the drawback of surgical treatment of AF in CABG is the need to open the left atrium for the Cox-Maze procedure, the most effective surgical ablation technique (13). Though multiple studies have demonstrated that surgical ablation with CABG improves long-term results, mortality, and stroke rates, the downside remains. The same review states that a box lesion with accompanying LAAO has an 80% success rate in PAF patients but much lower success rates in non-PAF patients. The medical community’s expectation that the only treatment for non-PAF is MAZE III or MAZE IV procedure may be one reason for the low rate of concomitant surgical AF in CABG patients. Despite being the most common cardiac operation, only 33–70% of CABG patients with prior AF get concurrent surgical ablation (17-19).

In CABG patients with untreated preoperative AF, postoperative results, including mortality, are poorer (2,18-20).

With these facts in mind, we decided to perform PVI and LAAO in our AF population, regardless, if presenting with paroxysmal or persistent/long-standing persistent fibrillation and investigate the early and midterm results after having conducted these procedures. The results were encouraging in both groups. No consistent trend was observed between AF duration and rhythm outcomes. These findings suggest that AF type is the primary determinant of rhythm outcome, while duration provides additional descriptive context.

Seventeen of our cases were operated in beating-heart technique, thus only connecting the heart lung machine, but hereby avoiding a cardioplegic arrest, or a cross clamping of the aorta. The use of extracorporeal circulation is associated with a higher incidence of postoperative AF most likely as a result of an intensified systemic inflammatory response (21,22). This could be the explanation for the somewhat poorer results of the on-pump beating-heart group, but also this group included a higher percentage of patients with persAF and lspersAF, as well as with higher EuroSCORE II. From an electrophysiologic and perioperative standpoint, the off-pump approach may reduce systemic and atrial inflammation by avoiding cardiopulmonary bypass, potentially resulting in fewer early atrial arrhythmias. Moreover, the lower level of heparinization required in the off-pump setting [target activated clotting time (ACT) approximately 300 s] facilitates earlier and safer resumption of oral anticoagulation when indicated.

Currently, data on the optimal procedural techniques are limited and there is no apparent advantage of biatrial surgical ablation over PVI (23,24).

In a prospective multicenter German registry of 224 patients with CAD and AF, Vroomen and colleagues (11) compared on- vs. off-pump CABG (OPCAB) operation ablation procedures and postoperative results. Despite discrepancies in lesion set, rhythm result and safety were quantitatively similar (11). The on-pump group had higher PVI and extended left atrial lesion sets than the off-pump group. The primary lesion in the off-pump group was an atrial posterior wall box. Over 91% of patients in both groups received concurrent LAA management (11). SR at follow-up was confirmed in 61% of on-pump patients and 65% of off-pump patients, with no differences in in-hospital or follow-up complications (11). SR was restored in 76% of PAF patients off-pump and 65% on-pump (11). OPCAB surgery achieved 40% SR in non-PAF patients vs. 53% on-pump.

Most of their patients had PAF—60% on pump and 70% off pump. A majority of PAF patients (66.7% off-pump and 47.1% on-pump) were included in our study.

Their and our results suggest that isolating the pulmonary veins may be a good lesion set for rhythm management in CABG patients.

The authors further hypothesize that a reduction of myocardial oedema, inflammatory processes, and a more stable electrolyte balance might equalize the limitation in applying a more extensive setting in OPCAB surgery in the early postoperative period and this might also allow for sufficient electrical and anatomical remodelling, which could play a role in midterm outcome as well (11).

Further possible explanation of our good results is that left atrial occlusion was conducted as concomitant procedure in a high majority of cases and hereby also excluding it electrically and eventually prompting a higher SR rate at follow-up.

The hypothesis that patients with recent-onset AF may benefit from the concurrent operation once CABG has been planned is supported by the noticeably decreased AF recurrence in patients treated with surgical ablation. Future studies of larger scale and prospective design are necessary to assess the long-term clinical effects of ablation and LAAO in this specific and expanding patient population. The data from several single centre trials need to be strengthened, and there is a noticeable lack of power. Randomised control trials with consistent equitable AF monitoring are also essential, both for pretreatment AF diagnosis and postoperative monitoring purposes.

Limitations

This single-centre observational study has inherent limitations related to its retrospective design and relatively small sample size, which precluded randomization or propensity score matching. Although patient selection, surgical technique, and postoperative management were standardized, selection bias cannot be fully excluded, as patients with PAF were more frequently treated using the off-pump approach. This imbalance may have contributed to the higher SR rates observed in that subgroup. Detailed echocardiographic data on left atrial size were not consistently available, preventing reliable assessment of atrial dimensions. The exploratory EuroSCORE II stratification analysis was descriptive only and should be interpreted cautiously due to the limited number of patients and clinical events. Continuous rhythm monitoring was not routinely performed, and brief or asymptomatic recurrences could therefore have been missed, potentially leading to a modest overestimation of SR maintenance rates. Additionally, patient-centred outcomes such as NYHA class, functional capacity, or quality of life were not systematically captured. As the study was conducted in a high-volume centre with extensive experience in OPCAB and surgical AF ablation, the reproducibility of these results in lower-volume settings may be limited. Future prospective, multicenter studies with standardized functional assessments are warranted to validate and expand upon these findings.

Conclusions

PVI can be safely applied in both on-pump beating-heart and OPCAB settings. In both the initial PAF cohort and those with persistent or lspersAF, our study group achieved a significant proportion of SR during follow-up. Our findings endorse a consistent AF therapy alongside CABG surgery, also aspiring to elevate the indication and evidence class for concomitant AF surgery with CABG in forthcoming guidelines.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-464/rc

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-464/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-464/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-464/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of the Medical University Tübingen (ethics registration No. 776/2021B02 dated December 6, 2021) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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