Objective: To assess the 20-year results of emergency coronary artery bypass grafting (eCABG) for failed percutaneous coronary angioplasty (fPTCA). Methods: Between 1977 and 1997, 101 patients, (56±5)years (32 to 78 years), underwent eCABG (8.5±25) hours (1 to 168 hours) after fPTCA. The mean preoperative left-ventricular ejection fraction was (57±9)% (30 to 75%). Single-vessel disease (SVD) was found in 55%, two-vessel disease (TwVD) in 39% and triple-vessel disease (TrVD) in 15% of patients, with the left anterior descending coronary artery (LAD) being affected in 74%. 15% of patients had full cardiopulmonary resuscitation prior to eCABG. Results: The incidence of eCABG for fPTCA dropped from 29% (1977-82) to 6% (1983-87), 0.02% (1988-92) and to 0.004% (1993-97) (P=0.000). Patients mean age increased from (50±10) (1977-82) to (62±10) years (1993-97) (P=0.0001). The incidence of TrVD increased from 4% (1977-82) to 68% (1993-97) (P=0.0001), the LAD being dilated in 76% of patients between 1977-82 and in 36% between 1993-97 (P=0.009). Hospital mortality for eCABG was 5% and was stable over time. The use of the left internal mammary artery increased from 8% (1977-82) to 54% (1993-97) (P=0.006). After (14±4) years (1 to 20 years), the actuarial survival was (84±8)%, freedom from myocardial infarction (70±11)% and freedom from reoperation (58±17)%. Conclusion: PTCA has become a safe procedure despite the higher incidence of older patients with TrVD. eCABG for fPTCA carries an acceptable mortality with off-pump coronary artery surgical techniques already applie two decades ago. Patients surviving surgery have an excellent long-term survival.