Conventional coronary artery bypass grafting (CABG) utilizing cardiopulmonary bypass (CPB) and cardioplegic arrest has for many years represented the gold standard in coronary revascularization; however, this situation is now being challenged. Patients referred for CABG are older, have a higher incidence of co-morbid illnesses, greater severity of coronary artery disease, worse ventricular function, and more frequently require urgent or emergency procedures than compared with 10–20 years ago. Conventional CABG utilizing CPB in these high-risk groups is associated with high complication rates, substantially increased mortality and significantly increased costs. Coronary artery bypass grafts performed on the beating heart, without the use of CPB (off-pump or OPCAB) can achieve equivalent multi-vessel revascularization compared to conventional on-pump surgery, with a 25% reduction in cost and significantly better short-term outcome, particularly in high risk groups. Reduced morbidity and peri-operative costs, in turn, increase the quantity and quality of care that can be delivered by healthcare systems. Despite the apparent benefits however, debate continues as to the merits of off-pump surgery. The purpose of this review is to present critically the evidence obtained from randomized controlled trials, case-matched reports and observational studies and consider whether OPCAB will replace conventional on-pump as the gold standard for CABG over the next decade.