Objectives <p>The aim of this study was to examine bypass graft design assisted by virtual reality simulation in multi-vessel coronary artery bypass grafting.</p> Methods <p>Eight patients underwent coronary artery bypass grafting based on preoperative simulation for bypass graft design from February 2022 to February 2023 using holograms created using virtual reality software. In this virtual reality simulation, the lengths of the bilateral internal thoracic arteries were compared with virtual in situ internal thoracic arteries to evaluate whether targets could be reached. The actual length and pathway of in situ internal thoracic arteries on postoperative contrast-enhanced multidetector computed tomography were compared with the preoperative virtual reality simulation.</p> Results <p>In all cases, we were able to assess preoperatively whether the graft would reach the target and hence determine the bypass graft design. If the graft was not expected to reach the target, alternative designs could be considered. In no cases was the bypass graft design changed intraoperatively, and graft patency was 100% at 2&#xa0;years after surgery.</p> Conclusions <p>Assisted by virtual reality simulation, we were able to assess the location of the bypass anastomosis and required graft length and to determine the graft design, especially how to use the right internal thoracic artery.</p>