ITA-LAD anastomosis is the most valuable revascularization for long-term protection from myocardial infarction and cardiac death. This video precisely demonstrates technical details of off-pump beating heart anastomosia between the right internal thoracic artery (ITA) and the left anterior descending artery (LAD). This underwent triple arterial bypass ( RITA-LAD, LITA-CX, GEA-PLV). The SPY angiogram demostrateed good graft flow of each conduit prior to chest closure.