The surgical treatment of coronary artery anomalies continues to evolve. The most common coronary artery anomalies requiring surgical intervention include coronary artery fistulae, anomalous pulmonary origins of the coronary arteries, and anomalous aortic origins of the coronary arteries. The choice of surgical intervention for each type of coronary anomaly depends on several anatomic, physiologic, and patient-dependent variables. As surgical techniques have progressed, outcomes have continued to improve, however, controversy still exists about many aspects of the proper management of patients who have these coronary artery anomalies. We reviewed the surgical treatment of 178 patients who underwent surgery for the above-mentioned types of coronary artery anomalies at the Texas Heart Institute from December 1963 through June 2001. On the basis of this experience, we discuss historical aspects of the early treatment of these anomalies and describe their present-day management.