There are alternative operative strategies such as off-pump or beating heart, which have their own risks and benefits. These alternatives could be used when the risks of aortic manipulation outweigh the safe use of a cross-clamp or cannulation of the ascending aorta. Furthermore, surgeon experience with the strategies mentioned above should be considered.

• The risks and benefits of alternative operative strategies such as off-pump or beating heart, can be considered when the risks of aortic manipulation outweigh the safe use of a cross-clamp or cannulation of the ascending aorta.^[1]
• Furthermore, surgeon experience with the aforementioned strategies should be taken into consideration.
• One major concern that exists for the off-pump approach is the technical difficulty of bypassing coronary arteries in the circumflex distribution, in addition to small and intramyocardial segments. This concern created a tendency toward fewer grafts per patient, a higher rate of incomplete revascularization, and more concern regarding the graft patency in long term.^{[2][3][4][5][6][7][8]}
• The following are some of the advantages of off-pump coronary artery bypass surgery compared with on-pump CABG:^{[2][9][10][11][12]}
  • Earlier extubation
  • Lower rate of blood transfusion
  • Better outcome for patients with increased pulmonary disease risks
• Cardiopulmonary bypass is associated with a less systemic inflammatory response, and therefore has a less negative impact on pulmonary function.^{[2][9][10][11][12]}