Sixty patients with recurrent sustained ventricular tachycardia (VT) refractory to medical therapy underwent subendocardial resection. There were 52 men and 8 women, ranging in age from 39 to 74 years, all of whom had coronary disease. Each patient had had a prior infarction 1 week to 11 years prior to surgery and 52 had left ventricular aneurysms. The mean ejection fraction was 27%. All 60 patients underwent endocardial resection with or without aneurysmectomy guided by intraoperative and/or catheter endocardial mapping. Thirty-seven endocardial resections were from the interventricular septum, 14 from the interoposterior free wall, and 16 were from the anteroapical and anterolateral free wall. There were five (8%) surgical deaths. The 55 survivors underwent programmed stimulation in the control state 28 days following the operation. VT was not inducible in 42 patients (group A) and was inducible in 13 patients (group B). The group B patients underwent drug testing and were discharged on the antiarrhythmic agent that made the VT noninducible or more difficult to induce. There have been only four recurrences in sustained VT with a follow-up of 19 +/- 11 months. There have also been nine late nonarrhythmic deaths. The actuarial survival curve predicted 62% survival at 40 months. We conclude that activation guided endocardial resection provides long-term effective therapy for drug-resistant ventricular tachycardia.