The ability to restore myocardial perfusion in ischaemic heart disease has been one of the triumphs of surgery. Alternative, less invasive catheter-based methods have now taken the lead as favoured treatment. The resultant threat to surgical practice, as well as societal and organisational issues that impact on the life of surgeons, have caused many to question the future role of surgery in ischaemic heart disease. In spite of general awareness of risk factors, there is little to suggest that coronary disease will soon disappear; rather, obesity and unfavourable life-style of many will continue to recruit further patients and, additionally, an epidemic of heart failure is anticipated. At the same time, rapid advance in knowledge of the underlying disease is opening the prospect for more effective intervention for unstable coronary plaque. Of great relevance to the surgeon are recent advances in knowledge and technology that will lead to gene and cell-based therapy for ischaemic heart disease. The ability to modify or augment activity of myocytes in heart failure, and to promote angiogenesis, offers hope for repair of ischaemically damaged hearts undreamed of only a few years ago. Tissue engineering, encompassing gene and cell-based therapy, holds promise of reconstruction of the myocardium and its vasculature. Temporary cardiovascular support to enable application of these techniques will very likely provide one role for surgery. More importantly, the need to ensure optimal anatomic and functional repair will surely give rise to a new generation of surgeons with much expanded scientific and technical support to draw upon, and will ensure an important role for surgery in ischaemic heart disease for decades to come.