BACKGROUND: Advances in surgical myocardial revascularization (MR) have introduced additional benefits with the off-pump (OP) technique and the use of bilateral internal thoracic artery (ITA) grafting. Off-pump surgical MR has been associated with improved immediate outcomes and reduced incidence of perioperative complications, and the use of bilateral ITA grafts provides increased survival and decreased cardiovascular events in the long term. OBJECTIVE: To present the initial experience with the combined use of these advances in surgical MR. METHODS: A total of 35 consecutive patients undergoing off-pump MR with bilateral ITA grafting were studied; the left ITA was directed toward the anterior descending artery and the right ITA was anastomosed to the circumflex artery branches. The predominant comorbidities were previous myocardial infarction in 71.4% of the patients, diabetes mellitus in 34.2%, and renal failure in 14.2%. RESULTS No patients presented electrocardiographic changes or enzyme elevation in the postoperative period. The number of bypasses per patient ranged from two to four (median of three bypasses/patient). Postoperative hospital stay ranged from three to 12 days (mean of 4.7 + 1.7 days). No cases of sternal dehiscence or infection were observed, but one patient suffered a stroke on the fourth postoperative day and died. Late follow-up lasted from four to 48 months. No late deaths occurred, 31 patients are asymptomatic, and three have residual angina. CONCLUSION: The combination of these technical advances in surgical myocardial revascularization proved efficient and able to contribute to improved benefits in the long term.