Received: 3 June 2022 Revised: 13 June 2022 Accepted: 14 June 2022

DOI: 10.1111/iwj.13877

ORIGINAL ARTICLE

Surgical site wound infection, and other postoperative

problems after coronary artery bypass grafting in
subjects with chronic obstructive pulmonary disease:
A meta-analysis

Jinglin Gao1,2 | Huijuan Wang1 | Xiuhua Liu2 | Xinghui Song2 |

Xiaoning Zhong1

1
Department of Respiratory and Critical
Care Medicine, The First Affiliated
Abstract
Hospital of Guangxi Medical University, We performed a meta-analysis to evaluate the effect of chronic obstructive pul-
Nanning, People's Republic of China monary disease on surgical site wound infection, and other postoperative prob-
2
Department of Rheumatism and
lems after coronary artery bypass grafting. A systematic literature search up to
Immunology, The Fourth Affiliated
Hospital of Guangxi Medical University, April 2022 was performed and 37 444 subjects with coronary artery bypass
Liuzhou, People's Republic of China grafting at the baseline of the studies; 4320 of them were with the chronic

Correspondence
Xiaoning Zhong, Department of
Respiratory and Critical Care Medicine,
The First Affiliated Hospital of Guangxi
Medical University, Nanning, Guangxi
530021, People's Republic of China.
Email: jlgao188@sina.com
obstructive pulmonary disease, and 33 124 were without chronic obstructive
pulmonary disease. Odds ratio (OR), and mean difference (MD) with 95% con-
fidence intervals (CIs) were calculated to assess the effect of chronic obstruc-
tive pulmonary disease on surgical site wound infection, and other
postoperative problems after coronary artery bypass grafting using the dichoto-
mous, and contentious methods with a random or fixed-effect model. The
chronic obstructive pulmonary disease subjects had a significantly higher sur-
gical site wound infection (OR, 1.27; 95% CI, 1.01-1.60, P = 0.04), respiratory
failure (OR, 1.84; 95% CI, 1.55-2.18, P < 0.001), mortality (OR, 1.61; 95% CI,
1.37-1.89, P < 0.001), pneumonia (OR, 2.30; 95% CI, 1.97-2.68, P < 0.001),
pleural effusion (OR, 1.78; 95% CI, 1.12-2.83, P = 0.02), stroke (OR, 1.99; 95%
CI, 1.17-3.36, P = 0.01), and length of intensive care unit stay (MD, 0.73; 95%
CI, 0.19-1.26, P = 0.008) after coronary artery bypass grafting compared with
subjects without chronic obstructive pulmonary disease. However, chronic
obstructive pulmonary disease subjects did not show any significant difference
in length of hospital stay (MD, 0.83; 95% CI, 0.01 to 1.67, P = 0.05), and
pneumothorax (OR, 1.59; 95% CI, 0.98-2.59, P = 0.06) after coronary artery
bypass grafting compared with subjects without chronic obstructive pulmonary
disease. The chronic obstructive pulmonary disease subjects had a significantly
higher surgical site wound infection, respiratory failure, mortality, pneumonia,

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GAO ET AL. 303

pleural effusion, stroke, and length of intensive care unit stay, and no signifi-
cant difference in length of hospital stay, and pneumothorax after coronary
artery bypass grafting compared with subjects without chronic obstructive pul-
monary disease. The analysis of outcomes should be with caution because of
the low sample size of 1 out of 11 studies in the meta-analysis and a low
number of studies in certain comparisons.

KEYWORDS
chronic obstructive pulmonary disease, coronary artery bypass grafting, pleural effusion,
pneumonia, respiratory failure, surgical site wound infection

Key Messages
• we performed a meta-analysis to evaluate the effect of chronic obstructive
pulmonary disease on surgical site wound infection, and other postoperative
problems after coronary artery bypass grafting
• the chronic obstructive pulmonary disease subjects had a significantly
higher surgical site wound infection, respiratory failure, mortality, pneumo-
nia, pleural effusion, stroke, and length of intensive care unit stay after coro-
nary artery bypass grafting compared with subjects without chronic
obstructive pulmonary disease
• however, chronic obstructive pulmonary disease subjects did not show any
significant difference in length of hospital stay, and pneumothorax after cor-
onary artery bypass grafting compared with subjects without chronic
obstructive pulmonary disease
• the analysis of outcomes should be with caution because of the low sample
size of 1 out of 11 studies in the meta-analysis and a low number of studies
in certain comparisons

1 | INTRODUCTION illness for example, long mechanical ventilation, respira-

Chronic obstructive pulmonary disease is one of the lead-
ing causes of age-standardised mortality in the world, with
more than 3 million subjects dying from the disease.1
Chronic obstructive pulmonary disease is a common, pre-
ventable, and treatable disease that is characterised by per-
sistent respiratory symptoms persistent airflow restriction,
and remodelling of small airways.2 The contained lung tis-
sue remodelling includes pulmonary and systemic changes
in mucosal tissue, fibre types and fibrosis, lung vascular
remodelling, and angiogenesis. These pathological varia-
tions contribute to adverse effects on different extrapul-
monary organs in chronic obstructive pulmonary disease
subjects.3 Chronic obstructive pulmonary disease is a com-
mon comorbid disease in subjects experiencing coronary
artery bypass grafting, with a frequency of up to 20.5%.4
Usually, the chronic obstructive pulmonary disease is
known as a surgical contraindication to coronary artery
bypass grafting. In subjects specified for coronary artery
bypass grafting, chronic obstructive pulmonary disease
was shown to be related to higher postoperative death and
tory failure and atrial fibrillation.5 Presently, due to the
current advances in surgical techniques, anaesthesia, and
postoperative treatment, coronary artery bypass grafting is
done more frequently in subjects with chronic obstructive
pulmonary disease. Studies reported variable influences of
chronic obstructive pulmonary disease on postoperative ill-
ness and death. Surgical site wound infection and death
rates were shown to be similar between subjects with mild
to moderate chronic obstructive pulmonary disease and
those without chronic obstructive pulmonary disease,
while the only severe chronic obstructive pulmonary dis-
ease was related to increased death risk.6 Furthermore,
some studies have shown that the surgical site wound
infection and death rate of subjects undergoing coronary
artery bypass grafting were not affected by the severity of
airflow obstruction, and chronic obstructive pulmonary
disease was not an independent risk factor for higher death
and illness rates.7 Thus, the present study was performed
to assess the surgical site wound infection and other post-
operative problems after coronary artery bypass grafting in
subjects with chronic obstructive pulmonary disease.
304
2 | METHOD
2.1 | Study design
The current meta-analysis of included research studies
regarding the epidemiology statement,8 with a pre-
established study protocol. Numerous search engines
including, OVID, Embase, PubMed, and Google Scholar
databases were used to collect and analyse data.
2.2 | Data pooling
Data was collected from randomised controlled trials,
observational studies and retrospective studies investigat-
ing the effect of chronic obstructive pulmonary disease on
surgical site wound infection, and other postoperative
problems after coronary artery bypass grafting and study-
ing the influence of different outcomes. Only human stud-
ies in any language were considered. Inclusion was not
limited by study size. Publications excluded were review
articles and commentary and studies that did not deliver
a measure of an association. Figure 1 shows the whole
study process. The articles were integrated into the meta-
analysis when the following inclusion criteria were met:
1. The study was a prospective study, observation study,
randomised controlled trial, or retrospective study.
GAO ET AL.
2. The target population was subjects with coronary
artery bypass grafting.
3. The intervention program was based on subjects with
chronic obstructive pulmonary disease and without
chronic obstructive pulmonary disease.
4. The study included the subjects with the chronic
obstructive pulmonary disease compared with those
without chronic obstructive pulmonary disease.
The exclusion criteria were:
1. Studies that did not determine the influences of
chronic obstructive pulmonary disease on surgical site
wound infection, and other postoperative problems
after coronary artery bypass grafting.
2. Studies with subjects managed other than those with
chronic obstructive pulmonary disease and without
chronic obstructive pulmonary disease.
3. Studies did not focus on the effect of comparative
results.
2.3 | Identification
A protocol of search strategies was prepared according to
the PICOS principle,9 and we defined it as follows: P
(population): subjects with coronary artery bypass graft-
ing; I (intervention/exposure): subjects with chronic
F I G U R E 1 Schematic diagram of
the study procedure
GAO ET AL.
obstructive pulmonary disease; C (comparison): subjects
with the chronic obstructive pulmonary disease compared
with without chronic obstructive pulmonary disease; O
(outcome): surgical site wound infection, respiratory fail-
ure, mortality, pneumonia, pleural effusion, stroke, length
of intensive care unit stay, length of hospital stay, and
pneumothorax S (study design): no restriction.10
First, we conducted a systematic search of OVID,
Embase, Cochrane Library, PubMed, and Google Scholar
databases till March 2022, using a blend of keywords and
similar words for coronary artery bypass grafting, with
chronic obstructive pulmonary disease, without chronic
obstructive pulmonary disease, pneumonia, pleural effu-
sion, surgical site wound infection, and respiratory failure
as shown in Table 1. All the recruited studies were com-
piled into an EndNote file, duplicates were removed, and
the title and abstracts were checked and revised to
exclude studies that have not reported an association
between subjects with chronic obstructive pulmonary
TABLE 1 Search Strategy for Each Database
Database Search strategy
Pubmed #1 “coronary artery bypass grafting”[MeSH
Terms] OR “with chronic obstructive
pulmonary disease”[All Fields] OR “surgical
site wound infection”[All Fields] OR “pleural
effusion “[All Fields]
#2 “without chronic obstructive pulmonary
disease”[MeSH Terms] OR “coronary artery
bypass grafting”[All Fields] OR “pleural
effusion”[All Fields] OR “surgical site wound
infection”[All Fields] OR “pneumonia”[All
Fields]
#3 #1 AND #2
Embase ‘coronary artery bypass grafting’/exp OR ‘with
chronic obstructive pulmonary disease’/exp
OR ‘surgical site wound infection’/exp OR
‘pleural effusion’
#2 ‘without chronic obstructive pulmonary
disease’/exp OR ‘surgical site wound
infection’/exp OR ‘pneumonia’/exp Or
‘pleural effusion’
#3 #1 AND #2
Cochrane (coronary artery bypass grafting):ti,ab,kw (with
library chronic obstructive pulmonary disease):ti,ab,
kw OR (surgical site wound infection): ti,ab,
kw (Word variations have been searched)
#2 (pleural effusion):ti,ab,kw OR (without
chronic obstructive pulmonary disease):ti,ab,
kw OR (surgical site wound infection): ti,ab,
kw OR (pneumonia): ti,ab,kw OR (pleural
effusion): ti,ab,kw (Word variations have been
searched)
#3 #1 AND #2
305
disease and without chronic obstructive pulmonary dis-
ease after a coronary artery bypass grafting.
2.4 | Screening
Data were abridged on the following bases; study-related
and subject-related characteristics in a standardised form;
last name of the primary author, period of study, year of
publication, country, region of the studies, and study
design; population type, the total number of subjects,
demographic data, clinical and treatment characteristics,
categories, qualitative and quantitative method of evalua-
tion, information source, outcome evaluation, and statis-
tical analysis.11 When there were different data from one
study based on the assessment of the effect of chronic
obstructive pulmonary disease on surgical site wound
infection, and other postoperative problems after coro-
nary artery bypass grafting, we extracted them indepen-
dently. The risk of bias in these studies; individual
studies were evaluated using the two authors indepen-
dently assessed the methodological quality of the selected
studies. The “risk of bias tool” from the Cochrane Hand-
book for Systematic Reviews of Interventions Version
5.1.0 was used to assess methodological quality.12 In
terms of the assessment criteria, each study was rated
and assigned to one of the following three risks of bias:
low: if all quality criteria were met, the study was consid-
ered to have a low risk of bias; unclear: if one or more of
the quality criteria were partially met or unclear, the
study was considered to have a moderate risk of bias; or
high: if one or more of the criteria were not met, or not
included, the study was considered to have a high risk of
bias. Any inconsistencies were addressed by a reevalua-
tion of the original article.
2.5 | Eligibility
The main outcome focused on the assessment of the
effect of chronic obstructive pulmonary disease on surgi-
cal site wound infection, and other postoperative prob-
lems after coronary artery bypass grafting, and analysis of
the subjects with the chronic obstructive pulmonary dis-
ease compared with those without chronic obstructive
pulmonary disease were extracted to form a summary.
2.6 | Inclusion
Sensitivity analyses were limited only to studies reporting
and analysing the influence of chronic obstructive pul-
monary disease compared with those without chronic
306 GAO ET AL.

obstructive pulmonary disease. Comparisons between
subjects with chronic obstructive pulmonary disease and
without chronic obstructive pulmonary disease were per-
formed for subcategory and sensitivity analyses.
2.7 | Statistical analysis
The present meta-analysis was based on the dichotomous
and contentious methods with a random- or fixed-effect
model to calculate the odds ratio (OR), and mean differ-
ence (MD) with a 95% confidence interval (CI). The I2
index was calculated which was between 0 and 100 (%).
Values of about 0%, 25%, 50%, and 75% indicated no, low,
moderate and high heterogeneity, respectively.13 When I2
was more than 50%, the random effect model was
selected; while it was less than 50%, the fixed-effect
model we used. A subcategory analysis was completed by
stratifying the original evaluation per outcome categories
as described before. A P-value <0.05 was considered sta-
tistically significant for differences between subcategories
of the current analysis. Publication bias was evaluated
quantitatively using the Egger regression test (publication
bias considered present if P ≥ 0.05), and qualitatively, by
visual examination of funnel plots of the logarithm of
ORs versus their standard errors (SE).9 All P-values were
determined using 2 tailed test. The statistical analyses
and graphs were presented using Reviewer Manager
Version 5.3 (The Nordic Cochrane Centre, The Cochrane
Collaboration, Copenhagen, Denmark).
3 | RESULTS
A total of 1045 relevant studies were screened, of which
11 studies between 2006 and 2022, met the inclusion cri-
teria and were involved in the meta-analysis.14-24 Data
obtained from these studies were shown in Table 2. The
selected studies included 37 444 subjects with coronary
artery bypass grafting at the baseline of the studies; 4320
of them were with chronic obstructive pulmonary disease,
and 33 124 were without chronic obstructive pulmonary

T A B L E 2 Characteristics of the
Study Country Total With COPD Without COPD
selected studies for the meta-analysis
Fuster, 200614 Spain 1230 368 862
15
Manganas, 2007 Canada 322 221 101
16
Starobin, 2007 Israel 90 60 30
17
Lizak, 2009 Poland 3551 102 3449
Woods, 201018 USA 10 414 1739 8675
19
Stelle, 2011 USA 180 56 124
20
Najafi, 2015 Iran 564 273 291
21
Ho, 2016 Taiwan 15 564 706 14 858
Gür, 202022 Turkey 138 47 91
23
Wang, 2021 China 1800 154 1646
24
Gatta, 2022 UK 3591 594 2997
Total 37 444 4320 33 124

F I G U R E 2 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on surgical site wound infection outcomes in subjects with coronary artery bypass grafting
GAO ET AL. 307

F I G U R E 3 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on the incidence of the respiratory failure outcomes in subjects with coronary artery bypass grafting

F I G U R E 4 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on mortality outcomes in subjects with coronary artery bypass grafting

F I G U R E 5 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on pneumonia outcomes in subjects with coronary artery bypass grafting

disease. The study's size ranged from 90 to 15 564 subjects
at the start of the study. Eight studies reported data strati-
fied to the surgical site wound infection, 6 studies
reported data stratified to the respiratory failure, 8 studies
reported data stratified to the mortality, 7 studies reported
data stratified to pneumonia, 5 studies reported data strat-
ified to the pleural effusion, 5 studies reported data strati-
fied to the stroke, 8 studies reported data stratified to the
length of intensive care unit stay, 9 studies reported data
stratified to the length of hospital stay, and 4 studies
reported data stratified to the pneumothorax.
The chronic obstructive pulmonary disease subjects
had a significantly higher surgical site wound infection
(OR, 1.27; 95% CI, 1.01-1.60, P = 0.04) with low heteroge-
neity (I2 = 34%), higher respiratory failure (OR, 1.84; 95%
CI, 1.55-2.18, P < 0.001) with no heterogeneity (I2 = 20%),
higher mortality (OR, 1.61; 95% CI, 1.37-1.89, P < 0.001)
with high heterogeneity (I2 = 83%), higher pneumonia
(OR, 2.30; 95% CI, 1.97-2.68, P < 0.001) with low hetero-
geneity (I2 = 49%), higher pleural effusion (OR, 1.78; 95%
CI, 1.12-2.83, P = 0.02) with low heterogeneity (I2 = 41%),
higher stroke (OR, 1.99; 95% CI, 1.17-3.36, P = 0.01)
308 GAO ET AL.

F I G U R E 6 Forest plot of the effect of chronic obstructive pulmonary disease compared without chronic obstructive pulmonary disease
on pleural effusion outcomes in subjects with coronary artery bypass grafting

F I G U R E 7 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on the incidence of the stroke outcomes in subjects with coronary artery bypass grafting

F I G U R E 8 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on length of intensive care unit stay outcomes in subjects with coronary artery bypass grafting

F I G U R E 9 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on length of hospital stay outcomes in subjects with coronary artery bypass grafting

with no heterogeneity (I2 = 0%), and higher length of coronary artery bypass grafting compared with subjects
intensive care unit stay (MD, 0.73; 95% CI, 0.19-1.26, without chronic obstructive pulmonary disease as shown
P = 0.008) with high heterogeneity (I2 = 98%) after in Figures 2 to 8.
GAO ET AL.
F I G U R E 1 0 Forest plot of the effect of chronic obstructive pulmonary disease compared with without chronic obstructive pulmonary
disease on pneumothorax outcomes in subjects with coronary artery bypass grafting
However, chronic obstructive pulmonary disease sub-
jects did not show any significant difference in length of
hospital stay (MD, 0.83; 95% CI, 0.01 to 1.67, P = 0.05)
with high heterogeneity (I2 = 98%), and pneumothorax
(OR, 1.59; 95% CI, 0.98-2.59, P = 0.06) with no heterogene-
ity (I2 = 0%) after coronary artery bypass grafting com-
pared with subjects without chronic obstructive pulmonary
disease as shown in Figures 9 to 10.
It was not applicable to set adjustments of individual
factors such as gender, age, and ethnicity into stratified
models to study their effect on the comparison results
because there have been no reported data regarding these
variables. Moreover, there was no evidence of publication
bias (P = 0.86), according to the visual inspection of the
funnel plot and quantitative measurements using the Egger
regression test. However, most of the included randomised
controlled trials were shown to have low methodological
quality, no selective reporting bias, as well as relatively
incomplete outcome data and selective reporting.
4 | DISCUSSION
The current meta-analysis involved 37 444 subjects with
coronary artery bypass grafting at the baseline of the
studies; 4320 of them were with chronic obstructive pul-
monary disease, and 33 124 were without chronic
obstructive pulmonary disease.14-24 The chronic obstruc-
tive pulmonary disease subjects had a significantly higher
surgical site wound infection, respiratory failure, mortal-
ity, pneumonia, pleural effusion, stroke, and length of
intensive care unit stay after coronary artery bypass graft-
ing compared with subjects without chronic obstructive
pulmonary disease. However, chronic obstructive pulmo-
nary disease subjects did not show any significant differ-
ence in length of hospital stay, and pneumothorax after
coronary artery bypass grafting compared with subjects
without chronic obstructive pulmonary disease. The anal-
ysis of outcomes should be with caution because of the
low sample size of 1 out of 11 (≤100), and a low number
of studies in certain comparisons for example, pleural
effusion, stroke, and pneumothorax.
309
Chronic obstructive pulmonary disease is characterised
by a persistent airflow restriction and a remodelling of small
airways.2 In the lung of chronic obstructive pulmonary dis-
ease subjects, the chronic hypoxia-induced by airflow restric-
tion increases the activity of the angiotensin-converting
enzyme, which might additional negatively influence the
peripheral usage of oxygen and respiratory muscle function.
The activation of the renin-angiotensin system can result in
cell proliferation, hypertrophy, vasoconstriction, and inflam-
mation of the pulmonary vasculature. Furthermore, aldoste-
rone was shown to have a comparable influence on the
pulmonary vascular network, as it binds to mineralocorticoid
receptors promoting signalling pathways that contribute to
vascular remodelling.25 Angiogenesis with inflammation
plays a significant part in the remodelling of airways, which
might add to adverse effects on different extrapulmonary
organs in chronic obstructive pulmonary disease subjects.3
Therefore, the impact of severe lung disease for example,
chronic obstructive pulmonary disease on subjects experienc-
ing cardiac surgery was considered possibly dangerous for car-
diac surgery. In subjects experiencing coronary artery bypass
grafting, chronic obstructive pulmonary disease was shown to
be an independent risk factor for postoperative illness and
death.5 However, because of the present developments in
anaesthesia, cardiac protection, and surgical methods, and
the advances in preoperative pulmonary assessment and
medical optimization, it becomes probable to do coronary
artery bypass grafting with acceptable illness and death rates
in subjects with high risk. More studies have shown that sub-
jects with mild to moderate chronic obstructive pulmonary
disease or even chronic obstructive pulmonary disease did not
have a higher risk of postoperative death and illness rates than
those without chronic obstructive pulmonary disease.6,7
Though, a recent Chinese study still recommended chronic
obstructive pulmonary disease to be an independent risk fac-
tor for postoperative mortality after coronary artery bypass
grafting.26 In addition, there may be a selection of subjects
with the chronic obstructive pulmonary disease by surgeons
when coronary artery bypass grafting was done in these stud-
ies, for subjects with the mild-to-moderate chronic obstructive
pulmonary disease were at lower risk compared with those
with severe chronic obstructive pulmonary disease.
310
Since most comprised studies were from the last
decade, another possible rationale might be due to the
current developments in anaesthesia, cardiac protection,
and surgical techniques. Different pro-inflammatory
mediators formed through this procedure with the respi-
ratory muscle dysfunction by anaesthesia and surgery can
cause atelectasis in the basal lung segments and compro-
mise the gas exchange.27 All of these variations might pre-
dispose subjects to pulmonary infection and increase the
risk of pulmonary dysfunction, and even respiratory fail-
ure.28 Therefore, subjects with chronic obstructive pulmo-
nary disease might be incapable to tolerate an additional
decrease in lung function after coronary artery bypass
grafting and would develop more pulmonary problems.
As non-pulmonary illnesses, postoperative stroke and
renal failure were more recurrent among subjects with
chronic obstructive pulmonary disease. These outcomes
were in agreement with the study by Efird et al, in which
subjects with the chronic obstructive pulmonary disease
were found to have a higher rate of renal failure and
stroke than subjects without chronic obstructive pulmo-
nary disease.29 Rodrigues et al also confirmed that chronic
obstructive pulmonary disease was an independent risk
factor for renal failure after cardiac surgery.30 An addi-
tional significant difference between subjects with and
those without chronic obstructive pulmonary disease was
found in terms of surgical site wound infection. Chronic
obstructive pulmonary disease was shown to be signifi-
cantly related to surgical site wound infection in the cur-
rent meta-analysis. In the study by Meszaros et al, chronic
obstructive pulmonary disease was also shown to be an
independent risk factor for sternal wound infection.31
This meta-analysis showed the influence of chronic
obstructive pulmonary disease on surgical site wound
infection and other postoperative problems after coronary
artery bypass grafting.32-42 However, further studies are
still needed to illustrate these potential relationships as
well as to compare the effect of chronic obstructive pul-
monary disease compared with those without chronic
obstructive pulmonary disease on the outcomes studied.
These studies must comprise larger more homogeneous
samples. This was suggested also in a previous similar
meta-analysis study which showed similar outcomes for
subjects with the chronic obstructive pulmonary disease
on the surgical site wound infection and other postopera-
tive problems after coronary artery bypass grafting.43
Well-conducted randomised controlled trials are needed
to assess these factors and the combination of different
ages, ethnicity, and other variants of subjects; because
our meta-analysis study could not answer whether differ-
ent ages and ethnicity are related to the results.
In summary, The chronic obstructive pulmonary dis-
ease subjects had a significantly higher surgical site wound
GAO ET AL.
infection, respiratory failure, mortality, pneumonia, pleural
effusion, stroke, and length of intensive care unit stay after
coronary artery bypass grafting compared with subjects
without chronic obstructive pulmonary disease. However,
chronic obstructive pulmonary disease subjects did not
show any significant difference in length of hospital stay,
and pneumothorax after coronary artery bypass grafting
compared with subjects without chronic obstructive pul-
monary disease.
5 | LIMITATIONS
There may be selection bias in this study because so
many of the studies found were excluded from the meta-
analysis. However, the studies excluded did not satisfy
the inclusion criteria of our meta-analysis. The sample
size of 1 out of the 11 studies selected was ≤100. In addi-
tion, we could not answer whether the results are related
to age and ethnicity or not. The study designed to assess
the effect of chronic obstructive pulmonary disease on
surgical site wound infection and other postoperative
problems after coronary artery bypass grafting was based
on data from previous studies, which might cause bias
induced by incomplete details. Possible bias-inducing fac-
tors were the variables including age, sex, and the nutri-
tional status of subjects. Unfortunately, there might be
some unpublished articles and missing data which might
lead to bias in the studied effect.
6 | CONCLUSIONS
The chronic obstructive pulmonary disease subjects had
a significantly higher surgical site wound infection, respi-
ratory failure, mortality, pneumonia, pleural effusion,
stroke,and length of intensive care unit stay after coro-
nary artery bypass grafting compared with subjects with-
out chronic obstructive pulmonary disease. However,
chronic obstructive pulmonary disease subjects did not
show any significant difference in length of hospital stay,
and pneumothorax after coronary artery bypass grafting
compared with subjects without chronic obstructive
pulmonary disease. The analysis of outcomes should be
with caution because of the low sample size of 1 out of
11 studies in the meta-analysis and a low number of stud-
ies in certain comparisons.
F U N D I N G IN F O R M A T I O N
No external funding was provided for this study. The
authors had full access to all of the datasets incorporated
in this study and take complete responsibility for the
integrity of the data and accuracy of the data analysis.
GAO ET AL.
CONFLICT OF INTEREST
The authors declare that they have no competing interests.
DATA AVAILABILITY STATEMENT
The datasets analyzed during the current meta-analysis
are available from the corresponding author via reason-
able request.
ORCID
Xiaoning Zhong https://orcid.org/0000-0001-9733-6229
R EF E RE N C E S
1. Barnes PJ, Shapiro SD, Pauwels R. Chronic obstructive pulmo-
nary disease: molecular and cellularmechanisms. Eur Respir J.
2003;22(4):672-688.
2. Matarese A, Santulli G. Angiogenesis in chronic obstructive
pulmonary disease: a translational appraisal. Trans Med
@UniSa. 2012;3:49-56.
3. Kropski JA, Richmond BW, Gaskill CF, Foronjy RF,
Majka SM. Deregulated angiogenesis in chronic lung diseases:
a possible role for lung mesenchymal progenitor cells (2017
Grover Conference Series). Pulm Circ. 2017;8(1):204589321
7739807.
4. O'Boyle F et al. Long-term survival of patients with pulmonary
disease undergoing coronary artery bypass surgery. Eur J Car-
diothorac Surg. 2013;43(4):697-703.
5. Magovern JA, Sakert T, Magovern GJ Jr, et al. A model that
predicts morbidity and mortality after coronary artery bypass
graft surgery. J Am Coll Cardiol. 1996;28(5):1147-1153.
6. Samuels LE, Kaufman MS, Morris RJ, Promisloff R,
Brockman SK. Coronary artery bypass grafting in patients with
COPD. Chest. 1998;113(4):878-882.
7. Angouras DC, Anagnostopoulos CE, Chamogeorgakis TP, et al.
Postoperative and long-term outcome of patients with chronic
obstructive pulmonary disease undergoing coronary artery
bypass grafting. Ann Thorac Surg. 2010;89(4):1112-1118.
8. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of obser-
vational studies in epidemiology: a proposal for reporting.
JAMA. 2000;283(15):2008-2012.
9. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring
inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560.
10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement
for reporting systematic reviews and meta-analyses of studies
that evaluate health care interventions: explanation and elabo-
ration. J Clin Epidemiol. 2009;62(10):e1-e34.
11. Gupta S, Rout G, Patel AH, et al. Efficacy of generic oral
directly acting agents in patients with hepatitis C virus infec-
tion. J Viral Hepat. 2018;25(7):771-778.
12. Higgins JPT, Altman DG, Gotzsche PC, et al. The Cochrane
Collaboration's tool for assessing risk of bias in randomised tri-
als. BMJ. 2011;343:d5928.
13. Sheikhbahaei S, Trahan TJ, Xiao J, et al. FDG-PET/CT and
MRI for evaluation of pathologic response to neoadjuvant che-
motherapy in patients with breast cancer: a meta-analysis of
diagnostic accuracy studies. Oncologist. 2016;21(8):931-939.
14. Fuster RG, Argudo JAM, Albarova OG, et al. Prognostic value
of chronic obstructive pulmonary disease in coronary artery
bypass grafting. Eur J Cardiothorac Surg. 2006;29(2):202-209.
311
15. Manganas H, Lacasse Y, Bourgeois S, Perron J, Dagenais F,
Maltais F. Postoperative outcome after coronary artery bypass
grafting in chronic obstructive pulmonary disease. Can Respir
J. 2007;14(1):19-24.
16. Starobin D, Kramer MR, Garty M, Shitirt D. Morbidity associ-
ated with systemic corticosteroid preparation for coronary
artery bypass grafting in patients with chronic obstructive pul-
monary disease: a case control study. J Cardiothorac Surg.
2007;2(1):1-6.
17. Lizak MK, Nash E, Zakliczy nski M, Sliwka J, Knapik P,
Zembala M. Additional spirometry criteria predict postopera-
tive complications after coronary artery bypass grafting
(CABG) independently of concomitant chronic obstructive pul-
monary disease: when is off-pump CABG more beneficial? Pol
Arch Med Wewn. 2009;119(9):550-557.
18. Woods SE, Bolden T, Engel A. The influence of chronic
obstructive pulmonary disease in patients undergoing coronary
artery bypass graft surgery. Int J Med Med Sci. 2010;2(10):
308-313.
19. Stelle LM, Boley TM, Markwell SJ, Hazelrigg SR,
Vassileva CM. Is chronic obstructive pulmonary disease an
independent risk factor for transfusion in coronary artery
bypass graft surgery? Eur J Cardiothorac Surg. 2011;40(6):1285-
1290.
20. Najafi M, Sheikhvatan M, Mortazavi SH. Do preoperative pul-
monary function indices predict morbidity after coronary
artery bypass surgery? Ann Card Anaesth. 2015;18(3):293-298.
21. Ho C-H, Chen YC, Chu CC, Wang JJ, Liao KM. Postoperative
complications after coronary artery bypass grafting in patients
with chronic obstructive pulmonary disease. Medicine. 2016;
95(8):e2926.
22. Gür AK, Şahinalp Ş, Unal H. Results of coronary artery bypass
grafting surgery in female smokers and female patients who
make tandoori who had chronic obstructive pulmonary dis-
ease. Eastern J Med. 2020;25(1):1-7.
23. Wang R, Tomaniak M, Takahashi K, et al. Impact of chronic
obstructive pulmonary disease on 10-year mortality after percu-
taneous coronary intervention and bypass surgery for complex
coronary artery disease: insights from the SYNTAX extended
survival study. Clin Res Cardiol. 2021;110(7):1083-1095.
24. Gatta F, Haqzad Y, Loubani M. Short-term and long-term
impact of diagnosed and undiagnosed chronic obstructive pul-
monary disease on coronary artery bypass grafting surgery.
Postgrad Med J. 2022;98(1158):258-263.
25. Dabul S, Bathgate-Siryk A, Valero TR, et al. Suppression of
adrenal βarrestin1-dependent aldosterone production by ARBs:
head-to-head comparison. Sci Rep. 2015;5(1):1-7.
26. Zheng Z, Zhang L, Hu S, et al. Risk factors and in-hospital
mortality in Chinese patients undergoing coronary artery
bypass grafting: analysis of a large multi-institutional Chinese
database. J Thorac Cardiovasc Surg. 2012;144(2):355-359.e1.
27. Tenling A, Hachenberg T, Tyden H, Wegenius G,
Hedenstierna G. Atelectasis and gas exchange after cardiac sur-
gery. J Am Soc Anesthesiologists. 1998;89(2):371-378.
28. Ng CS et al. Pulmonary dysfunction after cardiac surgery.
Chest. 2002;121(4):1269-1277.
29. Efird JT, Griffin W, ONeal WT, et al. Long-term survival after
cardiac surgery in patients with chronic obstructive pulmonary
disease. Am J Crit Care. 2016;25(3):266-276.
312
30. Rodrigues AJ, Evora PRB, Bassetto S, et al. Risk factors for
acute renal failure after heart surgery. Braz J Cardiovasc Surg.
2009;24:441-446.
31. Meszaros K, Fuehrer U, Grogg S, et al. Risk factors for sternal
wound infection after open heart operations vary according to
type of operation. Ann Thorac Surg. 2016;101(4):1418-1425.
32. Abdelrahim M, Assi KH, Chrystyn H. Dose emission and aero-
dynamic characterization of the terbutaline sulphate dose emit-
ted from a Turbuhaler at low inhalation flow. Pharm Dev
Technol. 2013;18(4):944-949.
33. Elgendy MO, Abdelrahim ME, Eldin RS. Potential benefit of
repeated dry powder inhaler's inhalation technique counseling
on asthmatic patients. Pulm Ther. 2015;1(1):91-101.
34. Madney YM, Fathy M, Elberry AA, Rabea H, Abdelrahim MEA.
Aerosol delivery through an adult high-flow nasal cannula circuit
using low-flow oxygen. Respir Care. 2019;64(4):453-461.
35. Harb HS, Elberry AA, Rabea H, Fathy M, Abdelrahim MEA.
Performance of large spacer versus nebulizer T-piece in single-
limb noninvasive ventilation. Respir Care. 2018;63(11):1360-
1369.
36. Harb HS, Laz NI, Rabea H, Abdelrahim MEA. Prevalence and
predictors of suboptimal peak inspiratory flow rate in COPD
patients. Eur J Pharm Sci. 2020;147:105298.
37. Nicola M, Elberry A, Sayed O, Hussein R, Saeed H,
Abdelrahim M. The impact of adding a training device to famil-
iar counselling on inhalation technique and pulmonary func-
tion of asthmatics. Adv Ther. 2018;35(7):1049-1058.
38. Osama El-Gendy A, Saeed H, Ali AMA, et al. Bacillus
Calmette–Guérin vaccine, antimalarial, age and gender rela-
tion to COVID-19 spread and mortality. Vaccine. 2020;38(35):
5564-5568.
GAO ET AL.
39. Saeed H, Ali AMA, Elberry AA, Eldin AS, Rabea H,
Abdelrahim MEA. Modeling and optimization of nebulizers'
performance in non-invasive ventilation using different fill vol-
umes: comparative study between vibrating mesh and jet nebu-
lizers. Pulm Pharmacol Ther. 2018;50:62-71.
40. Saeed H, Mohsen M, Salah Eldin A, et al. Effects of fill volume
and humidification on aerosol delivery during single-limb non-
invasive ventilation. Respir Care. 2018;63(11):1370-1378.
41. Saeed H, Mohsen M, Fink JB, et al. Fill volume, humidification
and heat effects on aerosol delivery and fugitive emissions dur-
ing noninvasive ventilation. J Drug Delivery Sci Technol. 2017;
39:372-378.
42. Saeed H, Salem HF, Rabea H, Abdelrahim MEA. Effect of
human error, inhalation flow, and inhalation volume on dose
delivery from Ellipta® dry-powder inhaler. J Pharm Innov.
2019;14(3):239-244.
43. Zhao H, Li L, Yang G, et al. Postoperative outcomes of patients
with chronic obstructive pulmonary disease undergoing coro-
nary artery bypass grafting surgery: a meta-analysis. Medicine.
2019;98(6):e14388.
How to cite this article: Gao J, Wang H, Liu X,
Song X, Zhong X. Surgical site wound infection,
and other postoperative problems after coronary
artery bypass grafting in subjects with chronic
obstructive pulmonary disease: A meta-analysis.
Int Wound J. 2023;20(2):302‐312. doi:10.1111/iwj.
13877