The therapy for patients with ischemic cardiomyopathy and advanced heart failure (AHF) is based on the optimal medical therapy, device-based therapies (implantable cardioverter-defibrillators and cardiac resynchronization therapy) and coronary revascularization. The decision to perform coronary artery bypass grafting (CABG) is difficult because of higher operative morbidity and mortality, uncertain benefit (lack of predictive factors including viability testing) and undefined guidelines. Ten-year of the follow-up from the largest randomized trial (STICHES) of CABG compared with medical therapy showed a mortality benefit in CABG patients (1). Percutaneous coronary intervention (PCI) seems to be reasonable alternative to CABG. However, there is a lack of clinical trials testing PCI versus medical therapy and CABG in AHF. The observational study that compared PCI using drug eluting stents with CABG in AHF patients showed no significant difference in death, greater risk of myocardial infarction and need for repeat revascularization but a significantly lower risk of stroke in PCI (2). In PCI patients in whom complete revascularization was achieved, there was no difference in myocardial infarction between PCI and CABG. However, PCI in AHF is considered as a high risk procedure and should be initiated only after full consideration of various factors and after developing a detailed plan. In our experience, there are some measures that need to be performed in order to improve outcome and to avoid complications. Important is to optimize patient’s clinical status and perform pulmonary decongestion. Staged approach to revascularization, especially in complex lesions, is preferred to avoid high total amount of contrast agents (leading to pulmonary oedema and contrast nephropathy) and cardiogenic shock in the case of abrupt artery closure (because of low contractile reserve). Suitable PCI support equipment should be timely considered (3). Because of low rate of complications (compared to the extracorporeal membrane oxygenation), easy to use and low price (compared to Impella), the intra-aortic balloon pump is especially convenient for short term haemodynamic support in patients where short ischemic period is expected during PCI.