Coronary artery bypass grafting utilizing the internal mammary artery (IMA) was performed in 108 patients with an operative mortality (less than 1 month) of 0% and a hospital mortality of 1.9%. The IMA was used most often in the left anterior descending artery system in combination with saphenous vein grafts (SVG) to the right and left circumflex artery systems. Although the IMA flow was smaller than the SVG flow when measured intraoperatively by an electromagnetic flow meter, postoperative clinical, electrocardiographic, isotopic, angiographic and coronary sinus flow-metric studies all demonstrated that the IMA can respond well to myocardial blood flow demand both at rest and during exercise, resulting in excellent clinical improvements with no detectable signs of flow deficiency. In addition, no signs of ischemia were detected in any of the 15 patients with stenosis in the left main trunk treated with an IMA graft. The IMA graft appears to have a great adaptive capacity to meet increased myocardial demand. Postoperative angiography performed at an average of 3 months after surgery in 60 unselected patients demonstrated an IMA patency rate of 98% in comparison with 88% patency in SVGs to the left anterior descending artery (p less than 0.05). Not only the patency rate, but also the graft wall characteristics were much better in IMA grafts than in SVGs. Some SVGs showed marked wall irregularity as early as 3 months after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)