This retrospective cohort study evaluated the impact of preoperative ischemic heart failure with reduced ejection fraction on long-term outcomes following coronary revascularization using either single or multiple arterial grafting techniques. Data from 59,641 patients (mean age 65.8 years; 81 percent male) across 59 cardiac centers (2001–2020) were analyzed, with patients stratified by perioperative left ventricular ejection fraction (EF). Over a median follow-up of five years, multiarterial grafting was associated with a 19 percent reduction in all-cause mortality for those with normal EF (hazard ratio [HR]=0.81, P<0.001), and similar benefits were observed in patients with mild (HR=0.83), moderate (HR=0.82), and severe left ventricular (LV) impairment (HR=0.82, P=0.01). Cox regression analysis showed no significant interaction between survival benefit and EF (P=0.75). Total arterial revascularization provided additional survival benefits except in cases with EF less than 30 percent (HR=0.87, P=0.30). These findings support the consistent survival advantage of multiarterial grafting across LV function levels and advocate for the broader use of these strategies.