Improvements in techniques in coronary revascularization over the past decade have led to a revival of interest in off-pump coronary artery surgery. A fifth of coronary revascularization procedures are now performed off-pump. Randomized trials comparing off-pump surgery with conventional coronary artery bypass grafting using cardiopulmonary bypass (CPB) mainly included low-risk patients and were therefore underpowered to detect a difference in mortality. Current evidence, however, suggests a significant reduction in morbidity with off-pump surgery. The avoidance of CPB and the elimination of any aortic manipulation may significantly reduce the risk of stroke. Those benefits are likely to be most marked in older, sicker patients, who represent an increasing proportion of the surgical population.