Because of the shortage of donor hearts, 16 (33%) of 48 patients with ischemic cardiomyopathy died awaiting transplantation. Determining factors that predict effective coronary revascularization and identifying patients who may benefit from revascularization is crucial. From 1984 to 1990, 207 ischemic cardiomyopathy patients were evaluated for heart transplantation; 131 were accepted (83 transplanted), 54 were not accepted, and 22 were revascularized (19 underwent bypass graft surgery and three underwent percutaneous transluminal coronary angioplasty). Four bypass patients failed early (less than or equal to 30 days, three deaths and one urgent heart transplant) and two late deaths (greater than or equal to 1 year) occurred. Overall mortality was 27%. Three-year survival of revascularized and transplanted patients was 72 +/- 10% and 73 +/- 6%, respectively. Successfully revascularized patients had preoperative ejection fraction, left ventricular end-diastolic dimension, and New York Heart Association functional class of 26 +/- 9%, 68 +/- 3 mm, and 3.9 +/- 0.4, respectively, compared with 36 +/- 9% (p less than 0.05), 64 +/- 6 mm (p = NS), and 1.2 +/- 0.4 (p less than 0.05) after revascularization. Preoperative ejection fraction of patients failing revascularization was 15 +/- 4% (p = NS compared with successful revascularization), and left ventricular end-diastolic dimension was 81 +/- 4 mm (p less than 0.05). Preoperative positron emission tomography imaging myocardial blood flow and glucose metabolism was performed in 12 patients: 10 patients with scans predicting reversible ischemia were successfully revascularized, and two patients with negative scans had failed revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)