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Objectives: To determine whether patients with critical left main stem (LMS) coronary artery disease can undergo off-pump coronary artery bypass (OPCAB) surgery safely and successfully. Methods: From May 1996 to March 2000 data for patients with critical ($50%) LMS stenosis who underwent conventional coronary artery bypass surgery with cardiopulmonary bypass (CCAB) or without (OPCAB) were collected prospectively using the Patient Analysis & Tracking System. A reusable pressure stabilizer, intra-coronary shunts and a single posterior pericardial stitch exposure technique were used in all OPCAB cases. Non-randomized, retrospective data analysis included demographic and preoperative risk factors, operative details, clinical outcome and early follow-up. Results: During the study period 387 patients with LMS stenosis underwent surgery (OPCAB na 75, CCAB na 312). Groups were similar in terms of preoperative and intraoperative variables although CCAB patients received significantly more grafts per patient (3.1 ^ 0.73 vs. 2.6 ^ 0.76, P # 0:001). Mortality was similar in both groups (OPCAB 1.3% vs. CCAB 2.6%). OPCAB patients when compared to CCAB patients had a lower requirement for postoperative inotropes (12.0% vs. 38.1%, Pa 0:0001), temporary postoperative pacing (2.7% vs. 10.1%, Pa 0:02), and blood product transfusion (6.7% vs. 31.4%, P , 0:0001), a lower incidence of postoperative chest infection (0% vs. 6.7%, Pa 0:02) and a slightly reduced postoperative length of stay (7.9 ^ 5.46 vs. 8.3 ^ 5.11 days, Pa 0:01). At 24 months follow-up, CCAB and OPCAB actuarial survival was 94.1 ^ 1.7% and 97.7 ^ 2.3%, respectively. Conclusions: OPCAB surgery is safe and effective in patients with critical LMS disease. q 2001 Elsevier Science B.V. All rights reserved.