 On the other hand, cardiac scores, including EuroSCORE and STS, have been developed to predict the risk of adverse outcomes following surgery. Frailty, an independent predictor of mortality and complications, is not included in these risk algorithms. Emerging evidence suggests that frailty is a better marker of biological age and more important than chronological age16,17. Afilalo et al.18 determined that patients with slow preoperative gait speed 6 s to walk 5 m had a 2 to 3 fold increased risk of mortality and major morbidity for any given level of STS-Predicted Risk of Mortality or Major Morbidity PROM compared with normal speed. Gait speed added to STS-PROM marginally increased model performance from 0.70 0.60-0.80 to 0.74 0.64-0.84. Forty-three percent of patients died or sustained a major complication assessed as high STS-PROM risk 15 together with slow gait speed, compared with 21.7 low STS risk with slow gait and 18.9 high STS risk with normal gait. Afilalo et al.19 subsequently evaluated the prognostic value of various frailty, disability and cardiac risk scores to identify the optimal combination to predict adverse outcome. Patients with slow gait speed and 3 impairments on the Nagi disability scale predicted in-hospital morbidity and mortality above that of the Parsonnet cardiac risk score AUC 0.76 vs. 0.72 with Parsonnet score alone. Lee et al.20 performed a retrospective review of a large cardiac registry, comparing outcomes between non-frail and frail individuals coded as having deficiencies in the activities of daily living, need for walking aids or diagnosis of dementia. Frailty was an independent risk factor for in-hospital mortality risk-adjusted odds ratio OR 1.8; 95 confidence interval CI 1.1-3.0; P0.03 and mortality at 2 years risk-adjusted hazards ratio HR 1.5, 95 CI 1.1-2.2; P0.01.The benefits of CABG without cardiopulmonary bypass in pre-frail and frail patients are still undetermined. In conclusion, frailty is defined as a geriatric syndrome of impaired resiliency to stressors such as cardiac surgery that has been delineated recently in the cardiovascular literature. However, the benefits of CABG without cardiopulmonary bypass in these patients are still undetermined. We believe OPCAB remains an important technique for the improvement of coronary surgery. The biggest question right now is whether pre-frail and frail patients will benefit more from off-pump or on-pump CABG. 