In patients with severe coronary disease and poor left ventricular function, coronary artery bypass grafting has a positive impact on long-term survival. In presence of angina or documented ischemia, it is beneficial in protecting functioning muscle against future infarction. In patients with heart failure and no angina, it is a rational option when large areas of akinetic but viable myocardium are identified preoperatively; under these circumstances, recovery of myocardial function is the goal of coronary revascularization. Obviously, reliable methods of assessing myocardial viability and contractile reserve are required for an accurate selection of patients. Advances in perioperative management, including myocardial preservation, have consistently reduced the operative risk in the most recent series, and more appropriate selection criteria have substantially contributed to the improved long-term survival. Variables associated with higher hospital mortality as well as factors influencing long-term outcome have been identified. The beneficial effect of coronary artery bypass grafting on the functional status of patients has been documented in several studies, and the improvement in left ventricular function has been objectively demonstrated. The concepts and the data presented in this review may help to define the present role of coronary artery bypass grafting in the treatment of ischemic cardiomyopathy.