BACKGROUND: The multifractal approach of HRV analysis offers new insight into the mechanisms of autonomic modulation of the diseased hearts and has a potential to depict subtle changes in cardiac autonomic nervous control not revealed by conventional linear and non-linear analyses in various conditions like heart failure or stable angina pectoris. The aim of this study was to employ the multifractality approach in cardiac surgery patients and evaluate the multifractality before and after beating-heart myocardial revascularization (off-pump CABG). METHODS: Twenty-four hour Holter recordings were performed pre- and postoperatively in 60 patients undergoing off-pump CABG. Selected conventional time- and frequency-domain linear HRV indices were calculated from the 24h and 5 min ECG segments, and preselected multifractal parameters tau(q=2), tau(q=3), h_top and Deltah were determined for daytime (12:00-18:00) and nighttime (00:00-06:00) periods of the ECG recordings using Ivanov\'s method. Mean differences over time were tested using paired-samples t-test and exact Wilcoxon matched-pairs test. The results are reported as mean +/- SD and median with interquartile range. A p value of <0.05 was considered statistically significant. RESULTS: All selected conventional linear HRV parameters decreased significantly after off pump CABG (p from <0.001-0.015). Preoperatively, multifractal parameter tau(q=2) was -0.60 +/- 0.12 and -0.54 +/- 0.12, tau(q=3) -0.52 +/- 0.18 and -0.49 +/- 0.17, h_top 0.20 +/- 0.07 and 0.15 +/- 0.07 and Deltah 0.31 +/- 0.14 and 0.17 +/- 0.14 for daytime and nighttime periods, respectively. Postoperatively, tau(q=2) and tau(q=3) were significantly higher for daytime (-0.49 +/- 0.15, p<0.001 and -0.43 +/- 0.23, p=0.015), whereas h_top and Deltah were significantly higher for both daytime and nighttime (0.25 +/- 0.07, p<0.001 and 0.19 +/- 0.06, p=0.002 for h_top and 0.41 +/- 0.20, p=0.003 and 0.31 +/- 0.19, p < 0.001 for Deltah, respectively). All pre- and postoperative parameters, except tau(q=2) and tau(q=3) preoperatively, were significantly lower for nighttime as compared to daytime periods. CONCLUSIONS: A significant breakdown of multifractal complexity and anti-correlation behavior with a significant sympathetic overdrive and a concomitant parasympathetic withdrawal occurs after off-pump CABG. The circadian pattern of multifractality regains its day-night variation in the first week after the surgical procedure.