Background

Severe left ventricular dysfunction (LVD), generally defined as a left ventricular ejection fraction (LVEF) ≤35%, is associated with increased morbidity, mortality, heart failure progression, and adverse cardiovascular events. Coronary artery disease (CAD) remains the leading cause of ischemic cardiomyopathy, making coronary revascularization a cornerstone of management.

Objective

To evaluate the role of percutaneous coronary intervention (PCI) in patients with severe left ventricular dysfunction, examine procedural challenges, review contemporary evidence, and discuss outcomes associated with modern revascularization strategies.

Methods

A comprehensive review of randomized trials, observational registries, meta-analyses, and contemporary guideline recommendations published between 2010 and 2025 was conducted. Data regarding clinical outcomes, procedural strategies, mechanical circulatory support, imaging guidance, and future developments were analyzed.

Results

Advances in PCI techniques, drug-eluting stents, intravascular imaging, physiological lesion assessment, and mechanical circulatory support have improved procedural safety and outcomes in patients with severe LVD. Complete revascularization appears associated with improved survival and reduced heart failure hospitalization. High-risk PCI supported by mechanical circulatory devices offers a viable option for patients unsuitable for surgery.

Conclusion

Coronary intervention in severe LVD patients remains challenging but increasingly successful with contemporary technologies. Careful patient selection, imaging-guided optimization, and multidisciplinary heart-team decision-making are essential for achieving favorable outcomes.