OBJECTIVE This study was designed to compare in-hospital mortality and complications and three-year mortality and revascularization for off-pump and on-pump coronary artery bypass graft (CABG) surgery after adjusting for patient risk. BACKGROUND The use of off-pump CABG surgery has increased tremendously in recent years, but little is known about its long-term outcomes relative to on-pump CABG surgery, and most studies have been very small. METHODS Short- and long-term outcomes (inpatient mortality and complications, three-year risk-adjusted mortality, and mortality/revascularization) were explored for patients who underwent off-pump CABG surgery (9135 patients) and on-pump CABG surgery (59044 patients) with median sternotomy from 1997 to 2000 in the state of New York. RESULTS Risk-adjusted inpatient mortality was 2.02% for off-pump versus 2.16% for on-pump (p = 0.390). Off-pump patients had lower rates of perioperative stroke (1.6% vs. 2.0%, p = 0.003) and bleeding requiring reoperation (1.6% vs. 2.2%, p < 0.001) and higher rates of gastrointestinal bleeding, perforation, or infarction (1.2% vs. 0.9%, p = 0.003). Off-pump patients had lower postoperative lengths of stay (median 5 days vs. 6 days, p < 0.001). On-pump patients had higher three-year survival (adjusted risk ratio [RR] =1.086, p = 0.045) and higher freedom from death or revascularization (adjusted RR = 1.232, p < 0.001). When analyses were limited to 1999 to 2000, the two-year adjusted hazard ratio for survival was not significant (adjusted RR = 0.99, p = 0.81). CONCLUSIONS On-pump patients experience better long-term survival and freedom from revascularization than off-pump patients. However, the survival benefit from on-pump procedures was no longer present in the last two years of the study.