Clinical experience is accumulating that coronary artery bypass grafting is of great benefit in patients with advanced ischemic cardiomyopathy. At Yale University, we have analyzed short- and long-term results in 188 consecutive patients with an ejection fraction (EF) of 30% or less undergoing coronary artery bypass grafting by a single surgeon. This experience permits the following conclusions: (1) Surgery can be performed safely (mortality 2.8% in elective patients); (2) Major improvement in left ventricular (LV) function is objectively demonstrable (EF change from 23.3% to 33.2%); (3) Symptomatic improvement is noted by patients (NYHA class change from 3.1 to 1.4); and (4) Good long-term survival is realized, relative to expectations with medical management alone (88%, 77%, and 60% at 1, 3, and 5 years). If coronary artery disease is severe and proximally situated and there are adequate target arteries, we do not deny patients surgery based on EF or LV size criteria, nor do we require objective demonstration of reversible ischemia. In fact, hearts in the largest size range (left ventricular end-systolic volume index > 100 mL) actually showed beneficial reverse remodeling subsequent to coronary artery bypass grafting. Surgical revascularization is recommended strongly for patients with advanced ischemic cardiomyopathy. Results rival those of transplantation.