Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF ≤35% underwent myocardial-revascularization. Patients received either OPCAB (n=256) or ONCABG (n=222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR)=1.05; p=0.93) and MACCE (13.7 vs. 17.6%; PS-OR=1.22; p=0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR=0.39; p=0.26), low cardiac output (2.3 vs. 4.7%; PS-OR=0.75; p=0.72) and stroke (2.3 vs. 2.7%; PS-OR=0.69; p=0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR=0.54; p=0.059) including renal dysfunction (PAOR=0.77; 95% CI 0.31-1.9; p=0.57), bleeding (PAOR=0.42; 95% CI 0.14-1.20; p=0.10) and respiratory failure (PAOR=0.39; 95% CI 0.05-3.29; p=0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR=0.75; p=0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularization