A 64 years old male diabetic patient with ejection fraction of 16% and renal dysfunction underwent off-pump CABG using both in situ internal mammary artery grafts. Left internal mammary artery was used to bypass left anterior descending artery and right internal mammary artery was used as composite graft. Patient had uneventful recovery and left ventricular ejection fraction improved to 34% within 8 months after surgery. In presence of left ventricular dysfunction, both internal thoracic artery grafting should be preferred for better patency rate and flow reserve. This is the first ever case report of anaortic off-pump bilateral internal thoracic artery grafting in a patient with left ventricular ejection fraction less than 20%.

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