Among 123 patients undergoing a direct operation, with or without other cardiac surgical procedures, for life-threatening ventricular tachycardia as a complication of ischemic heart disease, 68% of surviving patients were free of the return of ventricular tachycardia or sudden death 2 years after operation and 55% were free of these events at 5 years. The instantaneous risk (hazard function) of these events was highest immediately after operation and declined rapidly, so that by 3 months after operation instantaneous risk had merged with the constant-hazard phase which persisted as long as the patients were followed. More advanced impairment of left ventricular structure and function (with the exception of left ventricular aneurysm) increased the risk of occurrence of these events. Among patients with a negative electrophysiologic study (EPS) at hospital discharge, freedom from recurrent ventricular tachycardia or sudden death was 85% at 3 years. Survival, taking into account hospital deaths, was 54% 2 years after operation and 33% at 5 years. Most commonly (65% of instances) death was a result of acute, subacute, or chronic heart failure. The use of the technique of encircling endocardial myotomy increased the risk of death. Survival was particularly poor after the return of ventricular tachycardia. Direct operations for ventricular tachycardia are most likely to succeed in the presence of a discrete left ventricular aneurysm. The results are particularly unfavorable when there is severe global left ventricular dysfunction and no aneurysm. Improved myocardial protection during operation, and more specifically EPS-guided operations, may reduce the early risk of death and of return of ventricular tachycardia. The late return of ventricular tachycardia may be more related to a progressive secondary left ventricular cardiomyopathy than to an inadequate operation.