Background Direct surgical angioplasty of the left main coronary artery is aimed to restore a more physiologic flow of the left coronary artery compared with conventional coronary artery bypass graft surgery and allows subsequent percutaneous coronary interventions of more distal coronary lesions if necessary. Relatively little data are known about long-term outcome in these patients. Methods In 1996 and 1997, in 31 patients in our hospital, surgical angioplasty of the left main coronary artery was attempted. The left main coronary artery was approached in the anterior way. Follow-up was performed during 8 years and concluded by invasive anatomic and functional evaluation of the left main coronary artery. Results In 4 of these patients, the procedure was converted to conventional coronary artery bypass graft surgery owing to calcification of the left main coronary artery. Of the remaining 27 patients, 3 patients died in the perioperative period and 4 other patients died during follow-up. In 18 of the 20 survivors, coronary angiography was performed after 8 years, and the left main coronary artery was also evaluated by intravascular ultrasound and coronary pressure–based fractional flow reserve measurement. At angiography and intravascular ultrasound, a dilated funnel-shaped left main coronary artery was seen in all of these patients. In 1 patient, a hemodynamically significant left main coronary artery stenosis was present (fractional flow reserve < 0.75), and in this patient coronary artery bypass graft surgery was performed. Conclusions Although the total mortality of 23% was somewhat disappointing, the majority of the survivors had an excellent anatomic and physiologic result after direct surgical angioplasty of the left main coronary artery. Therefore, this technique deserves a place in the surgical armamentarium.