The use of the internal mammary artery (IMA) is recommended in elective aorto-coronary bypass grafting (CABG) because of favourable long-term patency results. In emergency CABG many surgeons prefer revascularization only with venous grafts due to the shorter operation time and higher initial flow rates of this type of graft. We investigated whether use of the IMA influences operative and mid-term results of emergency CABG after failed percutaneous transluminal coronary angioplasty (PTCA). From January 1990, to March, 1993, 56 emergency CABGs were performed in patients from 7 different cardiological centres where PTCA had failed. In 23 patients (Group A), the IMA was used as a bypass graft. In most of these patients the left IMA was anastomosed with the left anterior descending artery (n = 19). In one case both IMAs were used as bypass grafts. Venous grafts only were applied in 33 patients (Group B). Due to preparation of the IMA, aortic cross-clamp and bypass times were approximately 15 mins longer in Group A patients, although there was no significant difference in the number of grafts (1.7 +/- 0.8 in Group A vs. 1.5 +/- 0.7 in Group B). All patients of Groups A and B underwent echocardiographical investigations 14.6 +/- 8.2 months postoperatively. The overall mortality in Group A was 13% (n = 3) compared to 9% (n = 3) in Group B (p = 0.58). Significant predictors for death were age 65 years and over, diabetes mellitus, dilatation of the RCX and stenoses unfavourable for PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)