Background: The number of patients with severe left ventricular dysfunction referred for coronary artery bypass grafting (CABG) is increasing. Large number of studies showed that surgical intervention in this category of high risk patients had higher survival benefits and excellent outcome compared to medical therapy. Aim of work: Is to evaluate our experience with coronary artery bypass surgery in patients with EF ≤35% either to perform operation using off-pump technique or using cardiopulmonary bypass technique and try to reach conclusion about which technique may be safer regarding cardiac function and associated morbidities in this high risk group of patients. Patients and Methods: The prospective observational patient cohort study included 40 consecutive patients divided into 2 groups each of 20 patients selected according to surgeons experience in each technique. Results: Improvement of EF was encountered in our study; the mean 3-months postoperative EF increased for both groups increased nearly equal (36% versus 37%) for off-pump and on-pump groups respectively. There was no significant statistical difference in data collected for both groups (p-value>0.05) regarding all points of comparison. Renal dysfunction was slightly higher in the on-pump group but without reaching a significant difference (p-value>0.05). Conclusion: CABG in this high risk group has acceptable results with on-pump and off-pump techniques with nearly comparable results in our study in early 3-months postoperative period. Off-pump CABG seems to be valuable in this high risk group of patients with additional co-morbidities like renal dysfunction (p-value>0.05). However, larger studies are needed to confirm this point. Use of intra-aortic balloon in this high risk group of patients found to be beneficial when indicated. Inspite of lack of statistical significance (p-value >0.05, 3 patients developed renal dysfunction in on-pump group). Our study may suggest that off-pump technique may be safer for patients with renal dysfunction. Our study was designed for early (3 months) postoperative period and we did not include graft patency in our study. We recommend a longer follow-up period including follow-up of graft patency and postoperative viability study to reach more valuable data