Background: Coronary artery bypass grafting without cardiopulmonary bypass (CPB) is gaining popularity as an alternative to conventional on-pump techniques for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off pump (OPCAB) methods. There two approaches should be evaluated for financial and clinical appropriateness. Materials and Methods: Records of patients who had single or double bypass (IMA and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed.  These included 44 MIDCAB, 92 OPCAB and 243 conventional coronary artery bypass (CCAB) patients.  The pre-operative, intra and post-operative variables and clinical outcomes among these 3 groups were analyzed.  With univariate analysis, the MIDCAB and OPCAB patients were compared to the CCAB group.  The cost to perform each of these procedures was obtained from the participating institutions.  Results: MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4 ± 11 vs 2.3 ± 2.8, p=0.012), an increased incidence of reoperative status and preoperative COPD.  OPCAB patients had a higher predicted risk (5.3 ± 7.8 ), with greater incidence of co-morbidities of renal failure and prior CVA.  MIDCAB and OPCAB procedures required less OR time and utilized less blood products. The observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6% and CCAB 2.8% (NS). Mean hospital costs for each procedure were $21,000 CCAB, $19,000 for OPCAB and $17,000 for MIDCAB. Conclusion: Both MIDCAB and OPCAB procedures can be performed in selected patient populations without any statistical increase in major morbidity or mortality rates.  Off purap procedures are safe and currently reflect acute episode of care cost savings over CCAB.  Longitudinal comparison of these off-pump to on-pump procedures should be a priority.