Direct anastomosis of the end of the internal mammary artery to the side of the distal left anterior descending coronary artery with microsurgical technique produces an immediate increase in myocardial perfusion rather than a delayed increase as after mammary artery implantation. The distal left coronary artery is usually soft and widely patent even in patients with diffuse disease of this vessel. Seven consecutive patients have undergone this procedure; five had a simultaneous aorto-right coronary artery bypass with the saphenous vein. All but one survived and were markedly improved.