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AIM: To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. MATERIAL OF STUDY: We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). RESULTS:The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77.6% at 10 years and no significant difference in MACCE was observed (p=0.3016). DISCUSSION:Our results show a lower incidence of myocardial injury in OPCABG group, but there aren’t differences in term of MACCE in both groups. Recent studies have indicated the advantages of OPCABG in the elderly patients, reporting a reduction of postoperative morbidity and organ dysfunction. However these studies not analyzed the impact of LV dysfunction on early and late postoperative outcomes in high-risk patients. CONCLUSIONS:In the elderly with LV dysfunction, the OPCABG technique showed lower incidence of postoperative myocardial injury. However, at the follow-up, this does not reflect any significant differences in incidence of MACCE.