For over four decades, coronary artery surgery has been shown to relieve angina and extend life expectancy in patients with severe coronary artery disease. Pioneered in the 1960s, it has grown to become the most commonly performed and most intensively studied surgical procedure in the world, and remains the gold standard method for coronary revascularization, especially in patients with the most severe disease. Although increasingly challenged by percutaneous techniques using stents, the last decade has witnessed a significant reduction in surgical mortality (currently less than 1% in elective patients) and morbidity despite being applied in an increasingly older and sicker population. The use of arterial grafts, especially the left internal mammary artery, has resulted in significant improvements in long-term patency and clinical outcome. More recent technical advances include beating heart (off-pump) surgery and minimally invasive techniques.