1 presenting his personal opinions about off-pump coronary surgery (OPCAB) and concluding that it should be abandoned. It is our belief that these conclusions are based on several factual errors and multiple inaccurate statements.First, the statement "Retrospective nonrandomized, prospective randomized, and meta-analyses trials have failed to show any significant improvement in short-term morbidity or mortality with OPCAB techniques" is erroneous. Numerous large retrospective studies and meta-analyses have shown significant short-term improvements after OPCAB and comparable long-term outcomes.2-4 A recent risk-adjusted analysis of the national Society of Thoracic Surgeons database assessing 876 081 patients demonstrated a significant reduction in death and stroke (11% and 34% reduction, respectively) after OPCAB, seen in both low-and high-volume centers. Börgermann and colleagues 2 performed propensity matching on 1282 patients who underwent either a clampless OPCAB or an on-pump approach. A significant benefit for OPCAB was seen for mortality and stroke that remained visible at the 2-year follow-up, whereas the need for revascularization was comparable.Indeed, randomized, controlled trials have failed to demonstrate a significant mortality benefit for OPCAB. However, the available randomized, controlled trials were underpowered to detect significant differences between rarely occurring parameters such as stroke or death and importantly suffered from high selection and exclusion biases. Even more important is the fact that available randomized, controlled trials so far have primarily focused only on low-risk (Randomized On/Off Bypass [ROOBY; NCT00032630] or Coronary Artery Bypass Surgery Off or On Pump Revascularization Study [CORONARY; NCT00463294]) or elevated-risk (German Off Pump Coronary Artery Bypass in Elderly Study [GOPCABE; NCT00719667]) but not high-risk patients in whom the benefits of OPCAB have been repeatedly reported to be most apparent.3 The high conversion rates (12% in ROOBY, 7.9% in CORONARY, and 5% in GOPCABE) may suggest that some of the participating surgeons were inexperienced because expert centers report conversion rates between 2% and 4%, [2][3][4] which significantly affects long-term outcome.Second, Dr Lazar points out the important relation between incomplete revascularization and worse long-term outcomes. However, incomplete revascularization is not a shortcoming of OPCAB. This is a technical issue overcome by experience, as demonstrated by several reports. 4 Third, and most important, we disagree with the statement that "OPCAB does not completely eliminate the need for clamping." It is well documented that standardized application of no-touch, clampless strategies significantly eliminates the risk of calcific embolism from the ascending aorta resulting from clamping or declamping maneuvers.2,5 Moreover, we must emphasize that stroke can occur with any type of aortic manipulation, including cross-clamping, partial clamping, and aortic cannulation and during cardiopulmonary bypass. O...