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Corresponding author: Atsushi AmanoDepartment of Cardiovascular Surgery, Juntendo University2-1-1, Bunkyo-ku, Tokyo, 113-8421, JapanTEL&FAX: +81-3-3813-3210　E-mail: tyamamo@juntendo.ac.jp352nd Triannual Meeting of the Juntendo Medical Society “Farewell Lectures of Retiring Professors” 〔Held on Mar 31, 2021〕〔Received　Jun. 21, 2021〕〔Accepted　Nov. 25, 2021〕J-STAGE Advance published date: Feb. 16, 2022Copyright © 2022 The Juntendo Medical Society. This is an open access article distributed under the terms of Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original source is properly credited. doi: 10.14789/jmj.JMJ21-0012-R　Surgical treatment of ischemic heart disease began in 1945. After 1970, coronary artery bypass grafting (CABG) with cardiopulmonary bypass was developed along with coronary angiography. Juntendo University has been treating ischemic heart disease since 1980, and is actively performing off-pump CABG (OPCAB) since 2002. Besides the age of patients undergoing surgery, complications such as chronic hemodialysis, cerebrovascular disease, and malignancies make it challenging to reduce postoperative complications using OPCAB as graft preservation. OPCAB is technically challenging, and the CORONARY trial did not reveal its superiority over conventional CABG. Furthermore, high revascularization rates and technical differences among surgeons are important concerns. While not widely accepted in Europe and the United States, OPCAB comprises 65% of all stand-alone CABG in Japan. Japan reported a 2.5% hospital mortality rate in 2018, while the US reported 2.2% (according to the American Association of Thoracic Surgeons). In contrast, Juntendo University Hospital has maintained a 1% hospital mortality rate since 1984. To reduce the incidence of remote stroke in CABG patients, Juntendo has been using stroke-free management since 2010. Postoperative atrial fibrillation is 4-5 times more likely to recur than normal sinus rhythm after a 5-year course. In our study, 20% of patients suffered from chronic atrial fibrillation after ten years. Furthermore, left atrial appendage closure or amputation significantly reduces stroke in patients who undergo CABG and develop postoperative atrial fibrillation. Thus, OPCAB is a minimally invasive procedure with fewer complications; prevention of cardiogenic cerebral infarction can help improve remote outcomes.Juntendo Medical Journal2022. 68(2), 101-114Special ReviewsRefinement of Coronary Artery Bypass Grafting at Juntendo University HospitalIntroductionSurgical treatment of ischemic heart disease began in 1945 with the Veinberg operation, in which the left internal thoracic artery (LITA) was implanted into the myocardium1), followed by direct coronary revascularization with the great saphenous vein (SVG) in 19622). In 1969, Favaloro et al. reported the surgical results of 100 coronary artery bypass grafting (CABG) cases. The surgical mortality was excellent at 5%; LITA was used in 40% of cases, and graft patency was favorable in 80% of cases in one year3). After 1970, CABG under Key words: coronary artery bypass grafting, off-pump coronary artery bypass grafting, atrial fibrillation, stroke, left atrial appendageDepartment of Cardiovascular Surgery, Juntendo University, Tokyo, Japanthe arrested heart with cardiopulmonary bypass was the conventional procedure performed. Rapid advancements occurred in CABG and coronary angiography (CAG), which were developed in the same era. In 1975, the advantages of CABG over medical therapy were confirmed, particularly for left main trunk disease4). Since 1980, Juntendo University Hospital has been treating ischemic heart disease. Since 2002, we introduced off-pump CABG (OPCAB) technique and have been the world leader of the filed. In this review, we described our surgical strategy for ischemic heart disease along with the world trend of the field.101Atsushi AMANO