BACKGROUNDS Patients with multi-vessel disease and severe left ventricular dysfunction could benefit from percutaneous or surgical revascularization. However, given the high peri-procedural or operative risks, the selection of optimal treatment strategy is still challenging. METHODS We identified 327 patients with multi-vessel disease and severe left ventricular dysfunction (ejection fraction ��� 35%) who were treated from April 2003 to June 2009: 176 had undergone coronary-artery bypass grafting (CABG) and 116 had received percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Primary endpoint was the incidence of major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of death, myocardial infarction, stroke and target-vessel revascularization. RESULTS In a crude analysis, the 3-year, unadjusted rates of death (14% for PCI vs. 12% for CABG; p=0.58) and MACCE (25% for PCI vs. 17% for CABG; p=0.19) were similar between PCI group and CABG group. After the adjustment for difference in baseline characteristics, the risks of death (hazard ratio [HR] 1.48; 95% confidence interval [CI] 0.65 to 3.06; p=0.35) and MACCE (HR 1.59, 95% CI 0.83 to 3.06; p=0.162) were also comparable between the groups. However, the rate of TVR was significantly higher in the PCI group than in the CABG group (HR 12.3, 95% CI 1.52 to 100; p=0.019). CONCLUSIONS For patients with muti-vessel disease and severely compromised ventricular dysfunction, PCI with DES showed comparable long-term safety outcomes, but inferior efficacy outcomes, as compared with CABG.