Background: Off-pump coronary artery bypass grafting (OPCABG) in patients with low left ventricular ejection fractions (LVEF) < 30% mostly complicated by hemodynamic instability that is prevented by intra-aortic balloon pump (IABP). Compared to IABP, levosimendan can be used as it has a beneficial hemodynamic and cardioprotective effects with favorable outcome effect. Objectives: Was to compare the use of Levosimendan versus IABP in OPCABG patients with low LVEF in the early perioperative period. Patients and Methods: Between July 2019 and July 2021, a prospective randomized study was performed on a group of 60 patients with LVEF< 35%, who underwent elective OPCABG at Azhar University and Safa Hospitals. These patients were divided into 2 groups, according to the treatment they received – either levosimendan (Levo group) or IABP group. Hemodynamic parameters and cardiac function assessed as well as postoperative major events were recorded. Results: Cardiac functions were significantly improved postoperatively in IABP group compared to Levo group. Five minutes after induction, MAP was significantly lowered in IABP group compared to Levo group while CVP was significantly higher in IABP group compared to Levo group. There was a significant mechanical ventilation time among IABP group compared to Levo groups. And there were a significant more blood loss and higher incidence of AF and LCO in Levo group compared to IABP groups. Levo group had a significantly lower ICU stay than the IABP group with no statistically significant difference between them regarding mortality and morbidity. Conclusion: Levosemindan is easy to use and lowering the incidence of use of IABP and decreases hospital stay and morbidity for LVEF patients but can't be reached the effectiveness of IABP done by expert hands.