ORIGINAL ARTICLES: ADULT CARDIAC
ADULT CARDIAC
ADULT CARDIAC SURGERY:
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Impact of Off-Pump Coronary Artery Bypass Graft
Surgery on Postoperative Pulmonary Complications
in Patients With Chronic Lung Disease
Faraz Kerendi, MD, Michael E. Halkos, MD, John D. Puskas, MD,
Omar M. Lattouf, MD, Patrick Kilgo, MS, Robert A. Guyton, MD, and
Vinod H. Thourani, MD
Cardiothoracic and Vascular Surgeons, Austin, Texas; Division of Cardiothoracic Surgery, Emory University School of Medicine,
Atlanta; and Rollins School of Public Health, Emory University, Atlanta, Georgia
Background. Off-pump coronary artery bypass graft
surgery (OPCAB) has proven to be beneficial in many
high-risk subgroups. This study aims to determine
whether OPCAB lowers the incidence of pulmonary
complications among patients with chronic lung disease
(CLD) when compared with on-pump coronary artery
bypass graft surgery (ONCAB).
Methods. From 2002 to 2007, 7,060 patients underwent
isolated coronary artery bypass graft surgery in an aca-
demic center. Patients were classified according to sur-
gery type (ONCAB or OPCAB) and presence or absence
of CLD. A propensity score was produced to estimate
each patient’s likelihood of being assigned to OPCAB on
the basis of 39 preoperative risk factors. Multiple logistic
regression models and adjusted odds ratios with 95%
confidence intervals were used to evaluate the effect of
surgery type, CLD, and their interaction on pulmonary-
related complications and mortality.
Results. Among OPCAB patients, 15.3% (720 of 4,693)
had CLD compared with 11.2% (264 of 2,367) for ONCAB.
Off-pump coronary artery bypass graft surgery was per-
A s techniques in off-pump coronary artery bypass
graft surgery (OPCAB) have progressed, evidence
has emerged that high-risk patients with multiple asso-
ciated comorbidities may benefit from avoiding the del-
eterious effects of cardiopulmonary bypass [1, 2]. The
advantages of OPCAB have been demonstrated in a
multitude of retrospective studies as well as several
randomized controlled trials comparing OPCAB with
conventional on-pump coronary artery bypass graft sur-
Accepted for publication Aug 3, 2010.
Address correspondence to Dr Kerendi, Cardiothoracic and Vascular
Surgeons, PA, 1010 W 40th St, Austin, TX 78756; e-mail: fkerendi@
ctvstexas.com.
© 2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
formed in 73.2% of CLD patients compared with 66.5% in
those without CLD (p < 0.0001). Chronic lung disease
was associated with a greater incidence of prolonged
ventilation, reintubation, pneumonia, intensive care unit
hours, and non– home discharge. After propensity score
adjustment, OPCAB was associated with a significantly
reduced incidence of prolonged ventilation, pneumonia,
intensive care unit stay, and mortality. No significant
interactions existed between surgery type and CLD sta-
tus, suggesting that OPCAB was equally beneficial to
patients with and without CLD.
Conclusions. In this series, patients with CLD were
more likely to undergo OPCAB. Patients with CLD are at
significantly greater risk of pulmonary-related complica-
tions than patients without CLD. Off-pump coronary
artery bypass graft surgery reduced the incidence of
pulmonary complications and mortality in all patients.
Importantly, this benefit was seen similarly for patients
with and without CLD.
(Ann Thorac Surg 2011;91:8 –15)
© 2011 by The Society of Thoracic Surgeons
gery (ONCAB) [3, 4]. Many of these studies have shown
that OPCAB may be advantageous in certain high-risk
subgroups, including patients with left ventricular dys-
function [5, 6], renal failure [7, 8], and diabetes [9], and
elderly patients [10].
Patients with chronic lung disease (CLD) represent one
such high-risk subgroup, which represents a large per-
centage of cardiac surgery patients. Postoperative com-
plications in these patients may range from relatively
Dr Puskas discloses that he has financial relationships
with Medtronic and Maquet.
0003-4975/$36.00
doi:10.1016/j.athoracsur.2010.08.003
Ann Thorac Surg
2011;91:8 –15
benign to life threatening (ie, respiratory failure requir-
ing tracheostomy, severe pneumonia, or acute respira-
tory distress syndrome). Despite this, there has been a
paucity of data regarding any potential benefit of OPCAB
in patients with CLD undergoing surgical coronary re-
vascularization. Although several studies have been de-
signed to evaluate the benefit of OPCAB on postopera-
tive pulmonary function, the results have been
contradictory. In a prospective, randomized controlled
trial comparing OPCAB with ONCAB at Emory, Staton
and associates [11] reported an improvement in gas
exchange and extubation times for OPCAB patients.
Other similar studies, however, have failed to confirm
these beneficial findings [12, 13].
We propose that there may be a disparity in outcomes
in that OPCAB may be of greater benefit in patients with
underlying CLD than in patients with comparatively
normal lung function. Therefore, the goals of this study
are to assess postoperative pulmonary complications
in patients with CLD undergoing coronary artery by-
pass graft surgery (CABG) and to compare outcomes of
OPCAB compared with ONCAB in patients with a
history of CLD.
Material and Methods
The Society of Thoracic Surgeons (STS) Adult Cardiac
Database was queried for all patients who underwent
primary isolated CABG at the Emory University Hospi-
tals between January 2002 and April 2007. This time
frame was chosen to coincide with the entire period
during which CLD was categorized as mild, moderate, or
severe in the institutional STS database. The study cohort
consisted of 7,060 consecutive patients, including urgent
and emergent patients. Medical records from this retro-
spective, single-center cohort study included demo-
graphic data, preexisting comorbidities, surgeon identity,
operative strategy, and clinical outcomes. The study was
approved by the Emory University Institutional Review
Board in compliance with the regulations of the Health
Insurance Portability and Accountability Act and the
Declaration of Helsinki, with a waiver for individual
patient consent.
Surgical Technique
Each patient underwent OPCAB or ONCAB, performed
at the discretion of faculty surgeons. Off-pump coronary
artery bypass graft surgery was performed with one of
several commercially available cardiac positioning and
coronary artery stabilizing devices, using techniques that
have been previously described. On-pump coronary ar-
tery bypass graft surgery was performed with standard
techniques, using roller head pumps, membrane oxygen-
ators, cardiotomy suction, arterial filters, cold antegrade
and retrograde blood cardioplegia, and moderate sys-
temic hypothermia (32° to 34°C). Patients who were
converted intraoperatively from OPCAB to ONCAB or
from ONCAB to OPCAB were entered into the database
and analyzed according to the operation they ultimately
received. Intraoperative conversion began to be recorded
KERENDI ET AL 9
OPCAB IN PATIENTS WITH LUNG DISEASE
ADULT CARDIAC
as part of the institutional database in 2004, when a data
field for conversion was introduced into the STS national
adult cardiac database. During the study period, 126
patients (1.8%) were converted from OPCAB to ONCAB.
No patients were recorded as having converted from
ONCAB to OPCAB. Of the 126 converted patients, 5 of
them died (4.0%), which is not statistically higher than
the nonconverted group (n ⫽ 127 deaths, 1.8%; p ⫽ 0.07).
Of the 5 converted deaths, 3 of them were in patients with
no CLD and 2 of them were in patients with mild CLD.
Long-Term Follow-Up
Long-term follow-up was derived from the Social Secu-
rity Death Index (SSDI) database. The SSDI is a public-
use national database of death records extracted from the
US Social Security Administration’s Death Master File
Extract. Persons who have died since 1963 who had a
social security number and whose death has been re-
ported to the SSA will be listed in the SSDI. Thus, for
each patient who died before the cutoff date of March 31,
2007, a mortality date was provided, allowing construc-
tion of Kaplan-Meier long-term survival curves. Cause of
death was not considered; this study seeks to describe
all-cause mortality between CLD and surgery types.
Demographics and Preoperative Data
Before analysis, preoperative risk factors for the out-
comes of interest were identified and harvested from the
STS database (Table 1). Standard STS definitions of each
risk factor and outcome were used (www.sts.org). Specif-
ically, mild CLD was defined as a forced expiratory
volume in 1 second of 60% to 75% of predicted or
treatment with oral bronchodilator or chronic inhaler
therapy. Moderate CLD was defined as a forced expira-
tory volume in 1 second of 50% to 59% of predicted or
chronic steroid therapy aimed at lung disease. Severe
CLD was defined as a forced expiratory volume in 1
second of less than 50% or room air partial pressure of
oxygen less than 60 mm Hg or room air partial pressure
of carbon dioxide greater than 50 mm Hg.
The institutional database was populated by trained
personnel devoted exclusively to this task; consequently,
missing data were scarce. Data were 100% complete for
the critical risk factors of interest (surgery type and CLD)
as well as for each major postoperative hospital outcome.
Data were missing for the following variables: body mass
index (n ⫽ 8; 0.1%), body surface area (n ⫽ 8; 0.1%),
height (n ⫽ 8; 0.1%), ejection fraction (n ⫽ 284; 4.0%), STS
predicted risk of mortality (n ⫽ 2; ⬍0.1%), last creatinine
level (n ⫽ 40; 0.6%), and weight (n ⫽ 3; ⬍0.1%).
Data Management and Statistical Analysis
All data for consecutive patients were entered into a
computerized cardiac surgical database, using the data
fields and definitions of the STS National Adult Cardiac
Database. Checks for data quality are used both at the
institutional level and before final entry into the STS
National Adult Cardiac Database. A multiple imputation
algorithm was used to impute values that reflect the
uncertainty surrounding the missing data. This was done
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Table 1. Preoperative Risk Factors and Demographics Used for Propensity Scoringa
No CLD CLD

ONCAB OPCAB p ONCAB OPCAB p

Risk Factor (N ⫽ 2,103) (N ⫽ 3,973) Value (N ⫽ 264) (N ⫽ 720) Value

Age (y) 61.5 (10.4) 62.8 (11.4)) ⬍0.001 63.4 (10.2) 65.6 (10.5) 0.003
Female sex 503 (23.9) 1,155 (29.1) ⬍0.001 95 (36.0) 274 (38.1) 0.55
Body mass index ((kg/m2)/100) 0.3 (0.12) 0.3 (0.17) 0.19 0.29 (0.07) 0.30 (0.19) 0.24
Cerebrovascular disease 280 (13.3) 593 (14.9) 0.09 101 (38.3) 210 (29.2) 0.007
Previous stroke 149 (7.1) 335 (8.4) 0.07 60 (22.7) 127 (17.6) 0.07
Diabetes 813 (38.7) 1,451 (36.5) 0.10 108 (40.9) 276 (38.3) 0.46
Chronic kidney disease 104 (5.0) 337 (5.7) 0.21 17 (6.4) 67 (9.3) 0.15
Dialysis-dependent renal failure 44 (2.1) 106 (2.7) 0.17 4 (1.5) 25 (3.5) 0.11
Congestive heart failure 401 (19.1) 647 (16.3) 0.006 82 (31.1) 230 (31.9) 0.79
Ejection fractionb 0.495 ⫾ 0.133 0.514 ⫾ 0.122 ⬍0.001 0.480 ⫾ 0.141 0.492 ⫾ 0.134 0.20
Left main disease (⬎50% stenosis) 582 (27.7) 952 (24.0) 0.002 87 (33.0) 184 (25.6) 0.02
Previous myocardial infarction 1,179 (56.1) 1,941 (48.9) ⬍0.001 173 (65.5) 422 (58.6) 0.049
Number of diseased vesselsb 2.70 ⫾ 0.53 2.51 ⫾ 0.67 ⬍0.001 2.70 ⫾ 0.55 2.57 ⫾ 0.64 0.001
Hypertension 1,708 (81.2) 3,243 (81.6) 0.70 224 (84.9) 609 (84.6) 0.92
Peripheral vascular disease 247 (11.8) 526 (13.2) 0.10 77 (29.2) 195 (27.1) 0.52
Current smoker 547 (26.0) 1,053 (26.5) 0.68 108 (40.9) 294 (40.8) 0.98
Previous smoker 1,411 (67.1) 2,674 (67.3) 0.87 218 (82.6) 619 (86.0) 0.19
Surgical status
Elective 1,434 (68.2) 2,885 (72.6) ⬍0.001 176 (66.7) 472 (65.6) 0.001
Urgent 462 (22.0) 969 (24.4) ... 68 (25.8) 229 (31.8) ...
Emergent 192 (9.1) 119 (3.0) ... 19 (7.2) 19 (2.6) ...
Salvage 15 (0.7) 0 (0) ... (0.4) 0 (0) ...
Previous cardiovascular intervention 709 (33.7) 1,277 (32.1) 0.21 127 (48.1) 300 (41.7) 0.07
Previous CABG 163 (7.8) 82 (2.1) ⬍0.001 19 (7.2) 16 (2.2) ⬍0.001
Previous PCI 332 (15.8) 640 (16.1) 0.74 48 (18.2) 115 (16.0) 0.41
Intraaortic balloon pump 258 (12.3) 146 (3.7) ⬍0.001 28 (10.6) 25 (3.5) ⬍0.001
STS predicted risk of mortality 0.029 (0.046) 0.022 (0.03) ⬍0.001 0.052 (0.06) 0.047 (0.06) 0.31
a
Year of surgery, surgeon identity, and eight indicators of missing variables were also included in the model. b
Mean ⫾ standard deviation.

CABG ⫽ coronary artery bypass graft; CLD ⫽ chronic lung disease; ONCAB ⫽ on-pump coronary artery bypass graft surgery; OPCAB ⫽
off-pump coronary artery bypass graft surgery; PCI ⫽ percutaneous coronary intervention; STS ⫽ Society of Thoracic Surgeons.

to avoid selection bias that can occur by deleting cases
with missing variables of interest. Ten data sets were
imputed, and parameter estimates of the ten data sets
were combined using methods originally described by
Schaffer [14]. Data were assumed to be missing at
random.
Patients were classified according to CLD and the
surgery type (OPCAB or ONCAB) they received. To
reduce the effect of selection bias, propensity scores,
described by Blackstone [15] and D’Agostino [16], were
calculated for each patient on the basis of 39 risk factors
available preoperatively. For the propensity score calcu-
lation, a multiple logistic regression model was used
nonparsimoniously to model OPCAB (yes or no) as a
function of all 39 risk factors (Table 1). The resulting
conditional probability of a patient receiving OPCAB is
the propensity score. The goal of the propensity score
adjustment is to “postrandomize” or “balance” the
groups with respect to their preoperative risk factors so
that nonconfounded comparisons of group effects can be
estimated in an unbiased fashion.
To statistically evaluate the main effects of CLD and
surgery type, three different multivariable logistic regres-
sion model types were constructed for each outcome of
interest. Adjusted odds ratios associated with OPCAB
and CLD, along with 95% confidence intervals, were
computed for each adverse outcome and each model
type. All logistic models were adjusted with the propen-
sity score. Primary outcomes of interest included pro-
longed ventilation (⬎48 hours), total ventilator hours,
need for reintubation, pneumonia, acute respiratory dis-
tress syndrome, total intensive care unit (ICU) stay (in
hours), non– home discharge, and 30-day mortality.
First, a model consisting of CLD as a dichotomous
variable (presence or absence), surgery type (OPCAB or
ONCAB), and their interaction was fit. If the interaction
was statistically insignificant, then that term was re-
moved from the model and the main effects alone were
evaluated. This model was primarily designed to evalu-
ate the effects of CLD and surgery type in unison and to
determine whether OPCAB lessened or worsened out-
comes in the presence of CLD. Second, a model consist-
Ann Thorac Surg KERENDI ET AL 11
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ADULT CARDIAC
Table 2. Unadjusted Outcomes of Patients With or Without Chronic Lung Disease According to Surgery Type
No CLD CLD

ONCAB OPCAB ONCAB OPCAB

Outcome (N ⫽ 2,103) (N ⫽ 3,973) p Value (N ⫽ 264) (N ⫽ 720) p Value

Prolonged ventilation (⬎48 h) 209 (10.0) 187 (4.9) ⬍0.001 45 (17.2) 73 (10.4) 0.005
Postoperative ventilator time (h)a 33.4 ⫾ 113.3 18.5 ⫾ 62.7 ⬍0.001 56.5 ⫾ 146 36.9 ⫾ 101 0.046
Reintubation 78 (3.7) 116 (2.9) 0.10 24 (9.1) 55 (7.6) 0.46
Pneumonia 104 (5.0) 125 (3.2) ⬍0.001 25 (9.5) 57 (7.9) 0.43
ARDS 12 (0.6) 6 (0.2) 0.004 1 (0.4) 5 (0.7) 0.57
Sepsis 42 (2.0) 28 (0.7) ⬍0.001 8 (3.0) 17 (2.4) 0.55
Permanent stroke 41 (2.0) 39 (1.0) 0.002 3 (1.1) 8 (1.1) 0.97
Reexploration for 42 (2.0) 96 (2.4) 0.30 4 (1.5) 24 (3.3) 0.13
bleeding/tamponade
Acute renal failure requiring 90 (4.3) 91 (2.3) ⬍0.001 14 (5.3) 35 (4.9) 0.78
dialysis
Atrial fibrillation 409 (19.5) 645 (16.2) 0.002 66 (25.0) 165 (22.9) 0.49
Home discharge (survivors) 1,934 (94.3) 3,731 (94.8) 0.36 217 (83.8) 625 (89.0) 0.028
In-hospital mortality 52 (2.5) 36 (0.9) ⬍0.001 7 (2.7) 18 (2.5) 0.89
30-day mortality 58 (2.8) 45 (1.1) ⬍0.001 8 (3.0) 21 (2.9) 0.93
a
Mean ⫾ standard deviation.

ARDS ⫽ acute respiratory distress syndrome; CLD ⫽ chronic lung disease; ONCAB ⫽ on-pump coronary artery bypass graft surgery; OPCAB ⫽
off-pump coronary artery bypass graft surgery.

ing of CLD severity (none, mild, moderate, severe) and Results

surgery type was constructed. This model compared the
Preoperative Risk Factors
severity levels of CLD to patients with no CLD, adjusted
The OPCAB group consisted of 4,693 patients (66.5%),
for the propensity score and surgery type. Third, a series
and the ONCAB group consisted of 2,367 patients
of four stratified models comparing surgery type within
(33.5%). A total of 647 patients (9.2%) were characterized
each CLD severity level (none, mild, moderate, severe)
as mild CLD, 148 (2.1%) as moderate CLD, and 189 (2.7%)
was fit to determine whether the effect of OPCAB differs
as severe CLD. Preoperative demographics and risk
across CLD severity. For continuous outcomes, OPCAB
factors are listed in Table 1 and compared for patients
and CLD main effects were compared with general linear
with and without CLD according to surgery type (OPCAB
models, adjusted for the propensity score.
versus ONCAB). Patients with CLD were more likely to
Long-term survival comparisons were made using Cox
undergo OPCAB compared to those without CLD (73.2%
proportional hazards regression (adjusted) models and
versus 66.5%; p ⬍ 0.0001). Among patients with CLD,
Kaplan-Meier product-limit estimates (unadjusted).
those undergoing OPCAB were older, but had a lower
Kaplan-Meier curves were generated that provide sur-
incidence of cerebrovascular disease, left main disease,
vival estimates at postoperative times. Differences be-
previous myocardial infarction, previous CABG, and
tween CLD level Kaplan-Meier estimates were deter-
need for intraaortic balloon pump. Among those without
mined by log-rank tests. These estimates include
CLD, OPCAB patients were older, more likely to be
operative deaths. Adjusted long-term survival compari-
female, and had a higher ejection fraction. They also had
sons were made by using Cox proportional hazards
a lower incidence of left main disease, previous myocar-
regression to model the instantaneous hazard of death as
dial infarction, previous CABG, need for intraaortic bal-
a function of CLD, surgery type, and their interaction,
loon pump, and higher STS predicted risk of mortality. All
adjusted for the propensity score and patient age. Hazard
other risk factors were similar between groups (Table 1).
ratios were generated for each model term along with
95% confidence intervals.
The data were managed and analyzed using SAS Unadjusted Outcomes
version 9.1 (SAS Institute Inc, Cary, NC) and STATA Comparison of unadjusted outcomes for patients without
version 9.0 (StataCorp, College Station, TX). Unadjusted CLD revealed that OPCAB was favorable, with signifi-
comparisons were performed with ␹2 tests and two- cantly fewer postoperative complications (including
sample Student’s t tests for categorical and continuous pneumonia, sepsis, acute respiratory distress syndrome,
predictors, respectively. All statistical tests were two- stroke, acute renal failure, and atrial fibrillation) as well
sided using an alpha level of 0.05 for significance. No as decreased in-hospital and 30-day mortality. Among
adjustments for multiple tests were made. patients with CLD, those who underwent OPCAB had a
 12 KERENDI ET AL Ann Thorac Surg
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ADULT CARDIAC

Table 3. Multiple Logistic Regression Analysis Comparing Outcomes on Basis of Presence or Absence of Chronic Lung Disease
and Surgery Type and Their Interaction
OPCAB AOR Surgery Type CLD AOR CLD Interaction
Outcome (95% CI) p Value (95% CI) p Value p Value

Prolonged ventilation ⬎48 h 0.52 (0.40, 0.68) ⬍0.0001 1.89 (1.33, 2.69) 0.0004 0.4258
Reintubation 0.77 (0.53, 1.12) 0.1790 2.59 (1.61, 4.18) ⬍0.0001 0.8440
Pneumonia 0.66 (0.47, 0.93) 0.0180 2.04 (1.29, 3.22) 0.0023 0.3625
ARDS 0.41 (0.12, 1.44) 0.1657 0.68 (0.09, 5.26) 0.7134 0.1146
Mean ICU stay (h) 31.8 vs 38.5 0.0008 41.3 vs 32.8 ⬍0.0001 0.4296
Home discharge (survivors) 1.07 (0.80, 1.45) 0.6428 0.33 (0.22, 0.48) ⬍0.0001 0.1961
30-day mortality 0.54 (0.31, 0.93) 0.0281 1.10 (0.50, 2.45) 0.8110 0.0652

AOR ⫽ adjusted odds ratio; ARDS ⫽ acute respiratory distress syndrome; CI ⫽ confidence interval; CLD ⫽ chronic lung disease; ICU ⫽
intensive care unit; OPCAB ⫽ off-pump coronary artery bypass graft surgery.

shorter postoperative ventilator time and were more
likely to be discharged to home (Table 2).
Multiple Logistic Regression Analysis
Separate multiple logistic regression models were cre-
ated to evaluate the effect of surgery type (OPCAB versus
ONCAB), presence or absence of CLD, as well as their
interaction after adjusting for 39 perioperative risk fac-
tors (Table 3). No significant interactions existed between
surgery type and CLD status, indicating that although
OPCAB was equally beneficial to patients with and
without CLD, there was no added disproportionate ben-
efit in those with CLD. Chronic lung disease was associ-
ated with significantly longer postoperative ventilator
and ICU times (p ⬍ 0.001), and a greater incidence of
reintubation (p ⬍ 0.001), pneumonia (p ⫽ 0.002), and
non– home discharge (p ⬍ 0.001). Off-pump coronary
artery bypass graft surgery significantly reduced postop-
erative ventilator and ICU times (p ⬍ 0.001 for both), as
well as the incidence of pneumonia (p ⫽ 0.018) and
30-day mortality (p ⫽ 0.028).
Outcomes were also examined based on the severity of
CLD—mild, moderate, or severe. When compared with
those without CLD, patients with mild, moderate, or severe
CLD all had a greater incidence of prolonged ventilator
requirement, reintubation, pneumonia, and non– home dis-
charge. In addition, those with severe CLD had a signifi-
cantly greater 30-day mortality compared with those with-
out CLD (Table 4). A comparison of OPCAB versus ONCAB
within each category of CLD severity, however, failed to
achieve statistical significance for any end point (Table 5),
further suggesting that OPCAB does not interact with
COPD severity levels.
Survival Analysis
One-, 3-, and 5-year survival rates are summarized in
Table 6. The adjusted Cox proportional hazards regres-
sion model revealed no OPCAB effect (hazard ratio ⫽
0.93; p ⫽ 0.49) on survival. However, compared with
patients without CLD, mild CLD patients had signifi-
cantly shorter survival (hazard ratio ⫽ 1.47; p ⫽ 0.002) as
did moderate (hazard ratio ⫽ 2.67; p ⬍ 0.001) and severe
(hazard ratio ⫽ 4.47; p ⬍ 0.001) CLD patients. Kaplan-
Meier survival estimates significantly differed according
to CLD severity level (p ⬍ 0.001; Fig 1), although surgery
type had no significant effect on long-term survival (p ⫽
0.06; Fig 2).
Comment
The results of this single-institution, retrospective cohort
study corroborate previous findings that CLD is a signif-
icant risk factor for postoperative pulmonary complica-
tions and mortality after CABG [17–19]. Specifically,
patients with CLD had longer postoperative ventilator
and ICU times and were at greater risk for reintubation,

Table 4. Multiple Logistic Regression Analysis Comparing Outcomes on Basis of Severity of Chronic Lung Disease (Mild,
Moderate, Severe)
Mild CLD vs None AOR Moderate CLD vs None AOR Severe CLD vs None AOR
Outcome (95% CI) (95% CI) (95% CI)

Prolonged ventilation ⬎48 h 1.66 (1.26, 2.20)a 2.71 (1.70, 4.34)a 3.36 (2.25, 5.01)a
Reintubation 1.97 (1.39, 2.81)a 3.78 (2.20, 6.48)a 4.58 (2.91, 7.21)a
Pneumonia 2.20 (1.60, 3.02)a 3.46 (2.05, 5.85)a 2.36 (1.36, 4.07)a
Non-home discharge 1.92 (1.45, 2.56)a 3.71 (2.38, 5.80)a 3.58 (2.38, 5.39)a
ARDS 2.22 (0.75, 6.60) 2.48 (0.33, 18.7) 2.21 (0.29, 16.8)
30-day mortality 1.59 (0.90, 2.82) 1.52 (0.47, 4.86) 3.65 (1.73, 7.70)a
a
Significantly different from no chronic lung disease at p ⬍ 0.05.

AOR ⫽ adjusted odds ratio; ARDS ⫽ acute respiratory distress syndrome; CI ⫽ confidence interval; CLD ⫽ chronic lung disease.
Ann Thorac Surg KERENDI ET AL 13
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Table 5. Multiple Logistic Regression Analysis Comparing Outcomes of Off-Pump Coronary Artery Bypass Graft Surgery
Versus On-Pump Coronary Artery Bypass Graft Surgery on Basis of Severity of Chronic Lung Disease (Mild, Moderate,
Severe)
OPCAB vs ONCAB Mild CLD OPCAB vs ONCAB Moderate OPCAB vs ONCAB Severe
Outcome AOR (95% CI) (N ⫽ 647) CLD AOR (95% CI) (N ⫽ 148) CLD AOR (95% CI) (N ⫽ 189)

Prolonged ventilation ⬎48 h 0.65 (0.32, 1.31) 1.38 (0.39, 4.94) 0.42 (0.15, 1.15)
Reintubation 0.78 (0.32, 1.90) 3.53 (0.62, 20.0) 0.53 (0.16, 1.79)
Pneumonia 0.72 (0.33, 1.61) 0.80 (0.20, 3.28) 0.87 (0.20, 3.75)
Non-home discharge 0.83 (0.43, 1.60) 0.83 (0.27, 2.51) 1.02 (0.36, 2.90)
ARDS 1.66 (0.09, 31.2) Not estimable Not estimable
30-day mortality 0.40 (0.10, 1.62) Not estimable Not estimable

AOR ⫽ adjusted odds ratio; ARDS ⫽ acute respiratory distress syndrome; CI ⫽ confidence interval; CLD ⫽ chronic lung disease; ONCAB ⫽
on-pump coronary artery bypass graft surgery; OPCAB ⫽ off-pump coronary artery bypass graft surgery.

pneumonia, and non– home discharge. We also found
that those with severe CLD had significantly higher
30-day mortality when compared with patients without
CLD and that the diagnosis of CLD is associated with
decreased long-term survival.
The primary objective of this study was to determine
whether OPCAB would reduce the incidence of postop-
erative pulmonary complications, particularly in those
with a preoperative diagnosis of CLD. Indeed, the risk-
adjusted occurrences of several important outcomes
were reduced in patients undergoing OPCAB, including
postoperative ventilator and ICU times, pneumonia, and
30-day mortality. Although these benefits were seen for
all patients, including those with and without CLD, we
did not show any additional disproportionate advantage
of OPCAB for patients with CLD.
Postoperative pulmonary complications account for a
significant increase in resource utilization and hospital
costs in cardiac surgery as these patients have longer ICU
and hospital stays and are frequently transferred to
rehabilitation facilities for further recovery. Various mea-
sures have been proposed to reduce the risk of pulmo-
nary complications, such as preoperative inspiratory
muscle training [20], smoking cessation, and the use of
systemic corticosteroids and antibiotics in selected cases
[18]. Likewise, routine postoperative use of incentive
spirometry and inhaled bronchodilators, as well as ade-
quate pain control may contribute to improved out-
comes. In addition to these measures, the results of the
present study indicate that avoidance of cardiopulmo-
nary bypass may be beneficial.
The precise mechanism by which OPCAB contributes
to improved pulmonary outcomes is unknown, but is
likely to be multifactorial. It has been proposed that the
systemic inflammatory state associated with cardiopul-
monary bypass results in increased lung vascular perme-
ability [21] and impairment of gas exchange, particularly
in patients with chronic underlying lung disease. In
addition to directly avoiding these deleterious effects,
OPCAB has been shown to result in reduced blood
transfusion requirements [4], which would indirectly pre-
vent further transfusion-related lung injury. Less blood loss
and increased hemodynamic stability in OPCAB patients
may also translate into earlier extubation, thereby avoiding
ventilator-related barotrauma and the potential infec-
tious risks associated with prolonged mechanical
ventilation.
Beyond the utilization of cardiopulmonary bypass,
there are additional surgical factors that may contribute
to pulmonary complications, which have not been ac-
counted for in this study. It has been postulated that
sternotomy and sternal spreading may lead to some

Table 6. Kaplan Meier Product-Limit Survival Estimates for

Each level of Surgery Type and Chronic Lung Disease
1-Year 3-Year 5-Year
Variable Survival Survival Survival

No CLD 0.961 0.931 0.903

Mild CLD 0.932 0.892 0.857
Moderate CLD 0.899 0.825 0.699
Severe CLD 0.799 0.687 0.641
All OPCAB Patients 0.958 0.923 0.891
All ONCAB Patients 0.943 0.909 0.883

CLD ⫽ chronic lung disease; ONCAB ⫽ on-pump coronary artery

Fig 1. Survival by chronic lung disease severity. Survival is de-
bypass graft surgery; OPCAB ⫽ off-pump coronary artery bypass creased in patients with mild, moderate (mod), and severe chronic
graft surgery. lung disease compared with those without chronic lung disease.
 14 KERENDI ET AL
OPCAB IN PATIENTS WITH LUNG DISEASE
ADULT CARDIAC
Fig 2. Survival by surgery type: -pump coronary artery bypass graft
surgery (OPCAB) versus on-pump coronary artery bypass graft sur-
gery (ONCAB). No significant difference is seen.
degree of pulmonary dysfunction by altering chest wall
mechanics. Off-pump coronary artery bypass graft sur-
gery is not beneficial in this regard, and in fact may be
disadvantageous, as a greater degree of sternal spreading
is required, particularly when grafting the lateral wall.
Also, when harvesting the internal mammary artery,
pleural preservation may have a protective effect on the
lungs. Although we do not have data regarding pleural
preservation, it has not been our standard practice to do
so. In addition, the use of both internal mammary arter-
ies may further confound the issue by violating both
pleural spaces. Indeed, patients in the CLD group were
less likely to have one (91.9% versus 93.6%) or both (5.6%
versus 9.4%; p ⫽ 0.0004) internal mammary arteries used.
This study has several additional limitations that must
be addressed. Although we have used propensity scoring
and multivariable regression analyses to adjust for pre-
operative risk factors, our data are retrospective and
carry the deficiencies inherent to a nonrandomized trial.
However, the large number of patients included in this
investigation would be difficult to enroll in a prospective
study. Despite including 5 years of data and more than
7,000 patients, there may have been important differ-
ences in the CLD group that we were unable to demon-
strate owing to a lack of power, particularly when ana-
lyzing groups based on the severity of CLD. Finally, the
classifications of CLD used in this study were based on
definitions from the STS Adult Cardiac Surgery Database
and not on any uniform objective preoperative assess-
ment of pulmonary function. Nevertheless, our results
indicate that the beneficial effects of OPCAB were seen
for all patients, not just those with a diagnosis of CLD.
In summary, patients with CLD are at significantly
greater risk of postoperative pulmonary complications and
mortality after CABG, and have decreased long-term sur-
vival. Although OPCAB did not reduce mortality in the
subgroup of patients with CLD, it was associated with a
significant reduction of pulmonary-related complications,
Ann Thorac Surg
2011;91:8 –15
including prolonged ventilation, pneumonia, ICU stay,
non– home discharge, and 30-day mortality in all patients.
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INVITED COMMENTARY
Pulmonary complications are a major source of morbidity
and mortality after cardiac surgery and have a signifi-
cantly prolonged intensive care unit (ICU) and hospital
stay [1]. Risk factors for pulmonary complications include
advanced age, reduced preoperative pulmonary func-
tion, current smoking, postoperative pain, poor cough,
effusions, abdominal distention, left internal mammary
artery harvest with pleural entry, and most importantly
poor cardiac function. The use of cardiopulmonary by-
pass (CPB) is believed to reduce postoperative lung
function by apnea and atelectasis during the bypass run,
by an increase in interstitial water, and by inflammatory
mediators and microemboli damage to the alveolar
membrane. In a large cohort study, the use of cardiopul-
monary bypass was an independent risk factor for post-
operative intubation beyond 48 hours [1]. In a small
prospective, randomized study of on-pump coronary
artery bypass (ONCAB) and off-pump coronary artery
bypass (OPCAB), it was found that the OPCAB group
had improved gas exchange and had earlier extubation
when compared with ONCAB [2]. Therefore, should we
try to avoid CPB, especially in those patients with re-
duced pulmonary function when performing bypass
surgery?
The large retrospective study by Kerendi and col-
leagues [3] tries to analyze the difference between OP-
CAB and ONCAB vis a vis pulmonary complications in
patients classified preoperatively as having no, mild,
moderate, or severe lung disease. They are to be com-
mended for demonstrating the relationship between the
risk of pulmonary complications, early mortality, and
long-term mortality to the severity of preoperative lung
disease. This is important information and may help in
our preoperative decision-making process.
They also applied robust statistical applications to
achieve their conclusion that OPCAB reduced the inci-
dence of pulmonary complications in all patients as
compared with ONCAB; although true, this statement
requires clarification and should be nuanced. The great-
est impact of OPCAB in reducing prolonged ventilation,
ventilator time, pneumonia, ARDS, sepsis, in hospital
mortality, and 30-day mortality was among those patients
without preoperative lung disease. In those with lung
disease, only a reduction in prolonged ventilation and
ventilation times was noted. When comparing OPCAB
with ONCAB within each category of lung disease, there
was no significant difference in primary endpoints
among groups. One would have believed that if OPCAB
© 2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
KERENDI ET AL 15
OPCAB IN PATIENTS WITH LUNG DISEASE
ADULT CARDIAC
spiratory muscle training to prevent postoperative
pulmonary complications in high-risk patients undergo-
ing CABG surgery: a randomized clinical trial. JAMA
2006;296:1851–7.
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JM, Evans TW. Pulmonary vascular permeability after car-
diopulmonary bypass and its relationship to oxidative stress.
Crit Care Med 1997;25:425–9.
reduces pulmonary complications in a group without
lung disease, presumably by avoiding cardiopulmonary
bypass, then this effect should be even more pronounced
and concordant in a group of patients with lung disease.
Unfortunately, this does not seem to be the case.
It is known that a sternotomy, in addition to causing
pain and discomfort, will provoke a reduction in lung
volumes and impair rib-cage expansion and coordination
[4, 5]. During OPCAB, the sternum may be aggressively
retracted and stretched. It is believed that OPCAB de-
creases lung compliance due to increase lung fluid and
rotation of the heart during circumflex grafting [3]. Is it
possible that these mechanisms, and others yet identi-
fied, are as important in the development of pulmonary
complications as the use of cardiopulmonary bypass
among patients with pre-existing lung disease? Perhaps
the noted reduction in pulmonary complications among
those patients without lung disease undergoing OPCAB
is more of a reflection of different anesthetic and ICU
management and faster extubation rather than avoidance
of cardiopulmonary bypass.
At the present time, I believe that we are unable to
conclude that OPCAB should be performed preferen-
tially among patients with preoperative lung disease.
Kevin Lachapelle, MD
Cardiac Surgery
McGill University Health Center
687 Pine Ave W, Ste S8.30
Montreal, QC, Canada H3A 1A1
e-mail: kevin.lachapelle@muhc.mcgill.ca
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coronary artery bypass graft surgery on postoperative pulmo-
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Thorac Surg 2011;91:8 –15.
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