As an alternative method of myocardial protection and to obviate the inherent risks of cardiopulmonary bypass (CPB), we have been performing coronary artery bypass grafting (CABG) without CPB in carefully selected patients. Since the first such operation was successfully performed in January 1995 on a patient with angina pectoris and lung cancer, four other patients have subsequently undergone this technique. This series of 5 patients, being 1 man and 4 women ranging in age from 68 to 80 years, is presented in this report. The reasons for the selection of this procedure were concomitant diseases including lung cancer, a calcified aorta, and myocardial infarction. The mean time of ischemia for each anastomosis was 15.3 +/- 5.3 min, and the maximum cardiac muscle creatine phosphokinase (CPK-MB) was less than 14 unit/l postoperatively. None of the patients required ventilatory support for longer than 24 h postoperatively, and oral intake was started within 24 h after extubation in all patients. Postoperative angiography confirmed graft patency and none of the patients developed any ischemic symptoms. All the patients were discharged between 1 and 2 months postoperatively. Thus, the off-pump technique is useful when concomitant diseases are present and will become an alternative method of treatment for coronary artery disease in selected patients.