Off-pump coronary artery bypass (OPCAB) could be accomplished without cardiopulmonary bypass. However, no long-term outcomes or trends for OPCAB versus on-pump (ONCAB) use were recorded, nor were their long-term outcomes compared. Researchers used the national Veterans Affairs database to find isolated coronary artery bypass procedures (2005–2019). On an as-treated basis, procedures were classed as OPCAB on ONCAB. To assess longitudinal changes in OPCAB preference, trend analyses were conducted. The average follow-up duration was 6.6 years (3.5–10). An inverse probability-weighted Cox model was utilized to assess all-cause mortality between OPCAB and ONCAB. OPCAB was given to 6759 patients (average age 64±8) out of 47,685. (14%). The use of OPCAB has decreased from 16% in 2005–2009 to 8% in 2015–2019. The mean number of grafts obtained by patients with triple vascular disease who underwent OPCAB was lower (2.8±0.8 versus 3.2±0.8; P<0.01). The 5-, 10-, and 15-year survival rates for ONCAB were 82.9% (82.5–83.3), 60.4% (59.8–61.1), and 37.2% (36.1–38.4), respectively; OPCAB rates were 80.7% (79.7–81.7), 57.4% (56–58.7), and 34.1% (31.7–36.6) (P<0.01). OPCAB was linked to higher risk-adjusted all-cause mortality (1.15 [1.13–1.18]; P<0.01) and myocardial infarction (1.16 [1.05–1.28]; P<0.01). In Veterans Affairs medical centers, the use of OPCAB was decreased dramatically during the last 15 years. The OPCAB group had increased late all-cause death and myocardial infarction rates in Veterans Affairs hospitals.