Background Off-pump coronary artery bypass surgery (OPCAB) has been widely applied in recent years as a less invasive method of myocardial revascularization. This study evaluated the sequential bilateral intal mammary artery grafting combined with selective arterialization of the coronary venous system during OPCAB.Methods From April 2004 to August 2010, patients with diffuse right coronary lesions were studied retrospectively and divided into two groups. Group 1 included seventeen patients who underwent this surgery while group 2 included twenty-one patients without right coronary artery surgical therapy. All patients presented with symptoms of angina. Blood flow of bridged vessels was measured. The perioperative ventricular parameters including left ventricular ejection fraction and end diastolic diameter were compared. During follow-up, myocardial nuclide imaging and coronary angiography were carried out.Results Off-pump coronary artery bypass was performed with an average of 3.6 grafts per patient. Hospital mortality was zero. At the time of follow-up, the patients in group 1 recovered better than in group 2 (P＜0.05). In both groups, the mean New York Heart Association (NYHA) class and ejection fraction increased significantly (P＜0.001) and the mean left ventricular end-diastolic diameter decreased significantly (P ＜0.05). Myocardial blood supply of inferior wall in group 1 was obviously improved by myocardial nuclide imaging. Coronary angiography for eight patients in group 1 verified that there was blood flow to myocardium in the arterialized vein.Conclusions Sequential bilateral intal mammary artery grafting combined with selective arterialization of the coronary venous system can be performed during OPCAB. A postoperative improvement in the cardiac functions and the quality of life was documented, increasing our expectation for extensive application.