The success of "fast-track" accelerated recovery pathways in improving patient outcomes after coronary artery bypass graft surgery (CABG) has prompted expanded application. Although initially used only in routine cases, higher-risk cohorts may also benefit from this collection of management techniques. Twenty-seven consecutive patients with ejection fractions (EFs) less than or equal to 30 per cent (group I) undergoing CABG requiring cardiopulmonary bypass were started on our routine care path. The results of this effort were retrospectively compared with 27 concurrent patients with an EF greater than or equal to 50 per cent (group II) undergoing CABG at our institution. Outcome criteria included postoperative extubation (by 6 hours), transfer from intensive care unit (in < or = 24 hours), and hospital discharge on or before postoperative day 5. As anticipated, group I patients deviated from pathway criteria more frequently than did group II. However, despite severely compromised preoperative cardiac function, 52 per cent of group I patients were extubated within the first 6 hours postoperatively, 51 per cent were discharged from the intensive care unit on the 1st postoperative day, and 52 per cent were discharged from the hospital within the first 5 postoperative days. Group II patients' values for these parameters were 96, 96, and 70 per cent, respectively. No adverse effects could be attributed to pathway expectations. The results of this preliminary study suggest that accelerated care pathways may be safely applied to patients with severely low EFs and deserve further study.