From July 1978 through April 1983, 125 patients underwent attempted PTCA at the Massachusetts General Hospital. The first 25 patients were considered to be surgical candidates after failure of the PTCA attempt regardless of the presence of acute myocardial ischemia (Group I). The subsequent 100 patients (Group II) were considered to be surgical candidates only if acute myocardial ischemia was caused by a failed PTCA attempt. Four of the Group I patients (16%) required urgent operative intervention and 7 of the Group II patients (7%) required urgent operative intervention yielding, a total of 11 patients (8.8%) of the entire group. There were no hospital deaths and only 1 MI, actually documented before cardiopulmonary bypass. Women required urgent operative intervention more frequently than men (14.7% vs 6.6%). Patients with right coronary artery lesions required urgent operative intervention more often than those with left anterior descending lesions (13.0% vs 8.0%). Factors that lead to low operative mortality and myocardial infarction rates include an available operating room and team during the PTCA attempt, systemic arterial and Swan-Ganz pulmonary artery catheter pressure measurements at the time of angioplasty, intraaortic balloon pumping at the first sign of myocardial injury and expeditious surgery.