Despite more than 30 years of experience with coronary artery bypass grafting (CABG), controversy still exists on the optimal timing of surgical revascularization after acute myocardial infarction (AMI). Systemic fibrinolytic treatment and primary percutaneous coronary intervention (PCI) are both effective and represent the first-choice treatment for acute ST-segment elevation myocardial infarction (STEMI), although several randomized studies have shown that primary PCI is superior to thrombolytic therapy achieving early reperfusion and reducing mortality. In the last 2 decades, CABG during AMI was performed only in patients with mechanical complications or refractory cardiogenic shock (high mortality and morbidity rates). Emergency CABG in patients with STEMI is still associated with high mortality and morbidity, and the early outcome is poor compared with the outcome in patients with stable angina. Furthermore, it may be advisable to delay surgery whenever possible. However, in patients with STEMI, early surgery (within the first hours) is indicated. Current indications for emergency CABG in patients with STEMI are limited to those presenting with evolving myocardial ischemia refractory to optimal medical therapy, presence of left main stenosis or 3-vessel disease, ongoing ischemia despite successful or failed PCI, complicated PCI, or cardiogenic shock accompanied by complex coronary anatomy. Operative mortality for these patients using conventional OPCABG (On-pump coronary artery bypass grafting) is from 1.6% to 32% and strongly depends on the preoperative hemodynamic condition. The use of off-pump strategies for CABG is being still debated at present. Several retrospective studies have suggested the benefits of off-pump surgery in terms of in-hospital mortality and postoperative outcomes. This chapter focuses on the impact of off-pump surgery in patients with STEMI who undergo urgent CABG.