On-pump CABG was noted to be less technically complex and allowed better access to diseased coronary arteries in certain anatomic locations (eg, those on the lateral LV wall) as well as better long-term graft patency. In 2009, the results of the largest RCT to date comparing on-pump CABG to off-pump CABG, the ROOBY (Random- ized On/Off Bypass) trial, were published, reporting the outcomes for 2203 patients (99% men) at 18 Veterans Affairs Medical Centers.61 The primary short-term endpoint, a com- posite of death or complications (reoperation, new mechani- cal support, cardiac arrest, coma, stroke, or renal failure) within 30 days of surgery, occurred with similar frequency (5.6% for on-pump CABG; 7.0% for off-pump CABG; P 0.19). The primary long-term endpoint, a composite of death from any cause, a repeat revascularization procedure, or a nonfatal myocardial infarction (MI) within 1 year of surgery, occurred more often in those undergoing off-pump CABG (9.9%) than in those having on-pump CABG (7.4%; P 0.04). Neuropsychological outcomes and resource utiliza- tion were similar between the 2 groups. One year after surgery, graft patency was higher in the on-pump group (87.8% versus 82.6%; P 0.01). In short, the ROOBY inves- tigators failed to show an advantage of off-pump CABG compared with on-pump CABG in a patient population considered to be at low risk. Instead, use of the on-pump technique was associated with better 1-year composite out- comes and 1-year graft patency rates, with no difference in neuropsychological outcomes or resource utilization. 