According to the current guidelines coronary revascularization in acute coronary syndromes (ACS) is primarily performed by percutaneous coronary interventions (PCI). However, in several scenarios like complex coronary pathologies, unsuccessful PCI, complicated PCI or cardiogenic shock, surgical coronary revascularization might be indicated. Then, timing of the operation is based on clinical symptoms, coronary artery pathology, and the type of underlying ACS (Figure 1). Surgical strategies among others include the use of beating-heart strategies. Furthermore, a modern perioperative management allows improved results in a more aged and comorbid patient population as well as in patients presenting with hemodynamic instability. In cardiogenic shock, a variety of different cardiopulmonary assist devices are available today including intra-aortic balloon pump, several ventricular assist devices, and extracorporeal membrane oxygenation (Figure 2).In the literature, results of coronary artery bypass grafting (CABG) in ACS patients vary significantly because of different patient populations, different timing of the operation, and different hemodynamic status. Thus, comparison of surgical concepts is almost impossible. Until today, randomized surgical trials for ACS patients are pending. However, hospital survival of > 95% is reported even in emergency CABG patients during the last 5 years (Table 1). For all surgical candidates a close and direct communication between interventionalist and cardiac surgeon is mandatory to early identify the best treatment strategy and to achieve best possible revascularization results.