From 1978 to 1995, 1420 patients underwent direct coronary surgery without cardiopulmonary bypass (CPB). Among them 32 consecutive patients (2.2%) were operated on from 1984 to 1995 for acute transmural myocardial infarction. There were 27 males and 5 females (mean age 59.2 +/- 6.7 years; range 35-72). Mean extent of coronary artery disease was 2.1 vessels/-patient. Four patients were admitted to surgery in cardiogenic shock, 5 with life-threatening ventricular arrhythmias. A mean time of 311 +/- 109 min (range 100-685 min) was recorded between the onset of symptoms and surgical reperfusion. Patients were operated on using saphenous vein or left internal mammary graft. Intraoperative transmural myocardial biopsies were taken in the area of myocardial infarction, 15 minutes before and 45 minutes after revascularization: biopsy specimens showed a marked reduction in signs of mitochondrial and myofibril damage. No in-hospital death occurred. Postoperative low cardiac output was never recorded. One patient had a mediastinitis. All patients, except one who died 8 years postoperatively, are alive at present: 1 is NYHA class II, 1 in NYHA IV and 27 are asymptomatic, with yearly treatmill test negative for recurrent myocardial ischemia. One patient underwent redo surgery 7 years after surgery for recurrent angina. First 5 consecutive patients were studied angiographically 1 to 30 days after surgery: all grafts were detected patent. In conclusion coronary surgery without CPB may be considered an alternative to conventional surgical revascularization of myocardial infarction.