In the past there were many papers criticizing worse graft patency, incomplete revascularization and no clinical benefits in off-pump compared to on-pump CABG. How and when should we or may we perform off-pump coronary artery grafting? From surgical point of view the answer seems to be very simple. If we have to operate a patient whom we can’t make full revascularization, we shouldn’t perform OPCAB. However there are some exceptions. In some patients we can’t revascularizate one or more coronary arteries in both off- and on-pump technique. In such cases a safer procedure should be chosen. Sometimes surgeon is obliged to choose the lesser of two evils – what is most important in a particular case: a complete revascularization in on-pump CABG or less traumatic OPCAB operation . This question should be taken into account especially in high risk patients. According to Puscas and coauthors off-pump coronary artery bypass grafting is associated with lower operative mortality than coronary artery bypass grafting on CPB for higher risk patients [1]. Recently some other studies have demonstrate that the off-pump technique allows to operate the patients with less numbers of complications and good results in long-term observation. The five year follow-up in MASS III trial has shown that although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes [2]. The analysis of 30000 patients included in California CABG Outcomes Reporting Program has shown that OPCAB operation is associated with a significantly lower postoperative stroke rate compared with CABG even for older and higher risk patients However, intraoperative OPCAB to CPB conversion was associated with the highest postoperative stroke rate [3]. This last remark is crucial in daily clinical practice - what should be done to avoid conversions to CPB because of hemodynamic instability during off-pump operation? To avoid this complication many surgical moneuvres have been adapted by trial and error – deep pericardial stich, table rotation, pleuropericardial window, inotropic infusion and others. All cardiac surgeons who perform off-pump coronary artery bypass grafting have faith in the effectiveness of this moneuvres. However in medicine the faith is not enough. In one of his songs Leonard Cohen has sung – “Your faith was strong but you needed proof”. In the very interesting paper done by...


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