Such on-pump CABG has become the gold standard and is performed in about 80% of subjects undergoing the procedure in the United States. Despite the excellent results that have been achieved, the use of CPB and the associated manipulation of the ascending aorta are linked with certain perioperative complications, including myonecrosis during aortic occlusion, cerebrovascu- lar accidents, generalized neurocognitive dysfunction, renal dysfunction, and SIRS. In an effort to avoid these complica- tions, off-pump CABG was developed.58,66 Off-pump CABG is performed on the beating heart with the use of stabilizing devices (which minimize cardiac motion); in addition, it incorporates techniques to minimize myocardial ischemia and systemic hemodynamic compromise. As a result, the need for CPB is obviated. This technique does not necessarily de- crease the need for manipulation of the ascending aorta during construction of the proximal anastomoses. To date, the results of several RCTs comparing on-pump and off-pump CABG in various patient populations have been published.61,67,68 In addition, registry data and the results of meta-analyses have been used to assess the relative efficacies of the 2 techniques.69,70 In 2005, an AHA Scientific statement comparing the 2 techniques concluded that both procedures usually result in excellent outcomes and that neither technique should be considered superior to the other.71 At the same time, several differences were noted. Off-pump CABG was associated with less bleeding, less renal dysfunction, a shorter length of hospital stay, and less neurocognitive dysfunction. The inci- dence of perioperative stroke was similar with the 2 techniques. 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. 