In this paper we describe 1-year experience with a perspective operative protocol of emergency myocardial revascularization in extensive acute myocardial infarction (AMI). Entry criteria were: age < 75 years; anterior AMI with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular AMI, within 6 hours from symptom onset. After coronary arteriography, an emergency staff, composed by cardiologists and cardiac surgeons, addresses the patients to coronary artery bypass grafting (CABG) or to percutaneous transluminal coronary angioplasty (PTCA). From November 1994 to November 1995, 35 patients were enrolled: 19 (mean age 54.3 +/- 9.7 years) underwent CABG and 16 were treated with PTCA. Myocardial protection was such as to restore energetic substrates and to prevent reperfusion injury: surgical technique consisted of antegrade-retrograde substrate-enriched blood cardioplegic solution delivery, early cardioplegic delivery on the infarcting area via a saphenous graft, retrograde controlled reperfusion before aortic unclamping and then prolonged reperfusion of the infarcted myocardium. In 8 patients (mean age 50.9 +/- 8.6 years), with anterior AMI and stable hemodynamics, a left internal thoracic artery graft was used, performing the prolonged controlled reperfusion retrogradely before aortic unclamping. In hospital death occurred in 1/19 (5.3%) patients because of cerebral hemorrhage. At a mean follow-up of 5.1 +/- 3.7 months 17 patients (94.4%) were in NYHA functional class I-II and 1 patient (5.6%) complained of effort angina, that was well controlled with medical therapy. Left ventricular ejection fraction calculated by echocardiography preoperatively, before discharge and at follow-up was respectively 39.3 +/- 12.7, 43.1 +/- 8.9 and 43.4 +/- 9.0%. In the last 8 consecutive patients thermodilution and transesophageal echocardiography monitoring were performed preoperatively and 12 hours after CABG: in all cases ejection fraction and cardiac index increased after CABG, from 42.2 +/- 13.5 to 48.6 +/- 14.3% (p = 0.01) and from 2.8 +/- 0.5 to 3.4 +/- 0.6 l/min/m2 (p = 0.005), respectively. The preliminary results show the effectiveness of this perspective protocol in the management of critically ill patients with extensive AMI.