OBJECTIVE Postoperative stroke is the Achilles' heel of coronary artery bypass surgery compared with percutaneous coronary intervention. In this meta-analysis, we sought to determine the efficacy of the Heartstring proximal anastomotic device to reduce the risk of postoperative stroke after off-pump coronary artery bypass grafting (OPCAB). METHODS Studies on the Heartstring device were identified by searching PubMed, Cochrane Library and Scopus up to November 2010. The results were expressed as pooled proportions (%) with 95% confidence interval (95% CI). Heterogeneity across the studies was evaluated by the I(2) test and a random effects model was used. RESULTS Eighteen articles were pertinent with this issue and we were able to retrieve data on the Heartstring anastomotic device in OPCAB from eight studies. Three studies were prospective and routine epi-aortic ultrasound was used in three studies. A total of 819 patients were enrolled in these eight studies and six of them suffered stroke postoperatively. Cumulative analysis showed a pooled rate of immediate postoperative stroke after OPCAB with the use of Heartstring of 1.9% (95% CI 0.8-4.5, I(2)=23%). Sensitivity analysis including the only three studies evaluating patients with diseased ascending aorta as detected at epi-aortic ultrasound showed that a pooled rate of stroke was 3.2% (95% CI 0.8-11.9, I(2)=0%). Six studies reported on immediate postoperative mortality and the pooled mortality rate was 1.9% (95% CI 0.1-3.4). CONCLUSIONS The results of this meta-analysis suggest that the risk of stroke after OPCAB may not be markedly reduced by the use of Heartstring device. On the other hand, a rather low rate of stroke was observed among patients with diseased ascending aorta indicating its potential value in these patients. Most of studies included in this meta-analysis were of poor methodological quality, and properly conducted prospective studies are needed to get more conclusive results on the safety and efficacy of Heartstring anastomosis device.