Patients presenting for coronary artery bypass (CAB) surgery are now older and have more comorbid conditions. Off-pump (OPCAB) methods may reduce morbidity and mortality in these higher risk patients. Multivessel surgery has been limited by the difficulty in maintaining hemodynamic stability during lateral wall vessel grafting. Techniques for providing safe access to lateral wall vessels were applied in a largely unselected group of 665 OPCAB patients with emphasis on the avoidance of right ventricular compression. Safe access to essentially all target coronary arteries was achieved with very little need for pharmacological or mechanical support. No patient required new intraaortic balloon pumping and no patient required urgent conversion to cardiopulmonary bypass. Access to essentially all target coronary arteries can be achieved and myocardial performance can be maintained when strict attention is paid to operative strategies designed to minimize right-side heart compression.