Recommendation 91: We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF < 35%, graftable coronary arteries, and who are otherwise suitable candidates for surgery, irrespective of the presence of angina and HF symptoms to improve mortality, repeat hospitalization and quality of life (Strong Recommendation, Moderate Quality Evidence).

Recommendation 92: We suggest consideration of PCI for patients with HF and limiting symptoms of cardiac ischemia, and for whom coronary artery bypass grafting (CABG) is not considered appropriate (Weak Recommendation, Low Quality Evidence).

Recommendation 93: We recommend against routine performance of surgical ventricular restoration for patients with HF (Strong Recommendation, Moderate Quality Evidence).

Values and preferences: These recommendations are based on data from RCTs on CABG and surgical ventricular restoration in patients with reduced systolic function and CAD, regardless of the results of viability imaging. The recommendation on PCI is based on clinical need rather than RCT trial data.

• In the setting of HF, angina and single territory CAD, PCI might be the treatment of choice. However, PCI has not been shown to improve outcomes for patients with chronic stable HF, irrespective of underlying anatomy.
• In contrast to the chronic stable patient with HF, urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with ACS complicated by HF.
• In highly selected cases, patients with advanced HF symptoms in association with large areas of dyskinetic and nonviable myocardium might experience clinical improvement with SVR or similar type procedures, when performed by experienced surgeons.
• While mitral valve repair or replacement are both considered acceptable strategies for treatment of severe MR, it should be noted that the addition of mitral repair has not been shown to improve survival despite technical success. This is also the case for catheter based treatment of MR.

The Canadian Association of Cardiac Rehabilitation (CACPR) and CCS joint position statement includes routine cardiac rehabilitation for patients with HF who successfully complete CABG surgery.

Recommendation 94: We recommend that after successful cardiac surgery, all patients be referred to a local cardiac rehabilitation program (Strong Recommendation, High-Quality Evidence).

Values and preferences: These recommendations reflect our support of and conformity with pre-existing rehabilitation guidelines statements.