Off pump coronary artery bypass: a passing fad or ready for prime time?

Off pump coronary artery bypass (OPCAB) allows multivessel coronary disease to be bypassed surgically without the need for cardiopulmonary bypass, myocardial ischaemia, and in many cases ascending aortic manipulation. Many randomized controlled studies of OPCAB vs. on pump CABG (coronary artery bypass grafting) have been completed and published. Although non-inferior, OPCAB does not, in these trials, offer any clear benefits. As a consequence, surgeons and industry are losing interest in this undeniably harder technique. As the risk profile of patients being referred for coronary surgery is increasing, is it time for OPCAB to prove itself? A large, appropriately powered randomized controlled trial of OPCAB vs. on pump CABG in high-risk patients will determine whether it is now or never for OPCAB.