In this retrospective series overall results after reoperative coronary artery bypass surgery and the subsequent management of recurrent ischemic heart disease in these patients were reviewed. Between September 1980 and September 1993, 17% (n = 1300) of our patients (Pts) undergoing myocardial revascularization (CABG) were reoperative. Of these, 75% were male and 17% were > or = 70 years. One or both internal thoracic arteries (ITA) were used in 25% Pts; a saphenous vein graft (SVG) was used sequentially in 67% or as a separate conduit in 8%. Hospital mortality was higher after redo CABG than after primary CABG (6.9% vs 2.1%, p < 0.0001) and also in Pts receiving SVG rather than IMA as a conduit (7% vs 3.8%, p < 0.001), and in Pts receiving retrograde coronary sinus cardioplegia (RCSC) (n = 504) as compared to those who received antigrade cardioplegia since 1989 (n = 334) (2.5 vs 5.4%, p < 0.05). Throughout the series, independent predictors of hospital mortality by multivariate analysis were: female gender, postoperative myocardial infarction, congestive cardiac failure and stroke. Actuarial survival at 10 years for the patients receiving ITA as a conduit was 86% and for the patients receiving SVG only 76% (p < 0.02); for patients > 70 years was 66% and for patients < 70 years 80% (p < 0.005). Pts with a LVEF < 20% had a poor survival after 2 years. At 10 years cardiac related event free survival after 1st reoperation was 53%. During 13 years 94 Pts underwent subsequent reoperations and 125 Pts underwent saphenous vein graft angioplasty (PTCA), for recurrent ischemic heart disease. Cardiac event free survival at 6 years was clearly superior after multiple reoperative surgery than after graft angioplasty (45% vs 35% p < 0.05). In conclusion, in this series, use of the ITA as a conduit and RCSC has significantly improved Pts survival after redo CABG. Survival and quality of life were further improved in patients requiring multiple reop CABG or graft PTCA.