High risk patients scheduled for off pump coronary artery bypass (OPCAB) surgery imparts tremendous challenges to anesthetists. There is very little literature for the management of high risk patients subjected for off pump coronary artery bypass surgery. High risk patients have increased morbidity and mortality. The review describes the different causes of high risk patients, the problems faced during OPCAB and the management strategy. Risk stratification, optimization of organ functions prior to surgery, stable induction, maintenance and postoperative multidisciplinary team work will provide better outcome. Pre­induction precautionary arrangements of inotropes, defibrillator, intra aortic balloon pump, temporary pacemaker, back up of cardiopulmonary bypass and cell saver are useful for combating the cardiac emergencies. Along with routine monitors, pulmonary artery catheter, Transesophageal echocardiography, pulse contour (Flo Trac), noninvasive cardiac output monitors, bispectral index and near infrared spectroscopy play a major role to diagnose the critical events and hence help in prompt management.