A 62-year-old woman with ischemic cardiomyopathy (left ventricular ejection fraction, 15%) underwent HeartMate II (Thoratec, Inc, Pleasanton, CA) left ventricular assist device (LVAD) placement in January 2011 for cardiogenic shock. After implantation, the patient's hemodynamic status improved, but she had multiple episodes of ventricular tachycardia (VT) leading to implantable cardioverter-defibrillator therapies. The episodes led to marked reduction in LVAD flows and presyncope. Amiodarone, mexilitine, and quinidine therapy did not change the VT burden. The patient underwent endocardial catheter ablation in March 2011 at an outside institution. During this procedure, the basal lateral LV was noted to have low voltage consistent with scar, yet pace maps obtained in this region did not match the clinical VT. Despite extensive ablation of late potentials and scar border zones, the clinical VT remained inducible. In April 2011, the patient underwent epicardial mapping and ablation of VT at our institution. Because the patient had previous cardiac surgery and the 12-lead ECG of the clinical VT suggested a basal anterolateral exit, epicardial access was obtained by limited anterior thoracotomy in the cardiac catheterization laboratory, as described previously.1 Based on the clinical VT morphology and preprocedure CT, the fourth intercostal space was chosen for the incision (Figure 1A). Figure 1. CT scan, voltage map, and ECG. A , Preprocedure CT imaging demonstrating the left ventricular assist device inflow cannula site as well as …