Background: Combination of endocardial and epicardial approach has improved the overall success rate of ventricular tachycardia (VT) ablation in patients with cardiomyopathy. However, the origins of some VTs are truly intramural or close to coronary arteries, which make this combined strategy either prone to failure or too risky. Objectives: This observational study aimed to explore the feasibility and efficacy of direct epicardial ablation combined with intramural ethanol injection via surgical approach for such VTs. Methods: Six consecutive patients with recurrent sustained VT refractory to combined endocardial and epicardial radiofrequency ablation were included. Direct epicardial access was achieved through limited left thoracotomy in 3 patients and median sternotomy in other 3 patients. Ablation was performed using irrigation catheter guided by electroanatomic mapping. Ethanol was injected in all patients to reinforce transmural lesions. The primary outcome was freedom of sustained VT determined by device interrogation and periodical 24h-holter recordings subsequently. Results: Over a median follow-up of 22 months (range, 6~65), all patients remained free of sustained VT. One patient died of pulmonary infection one year after the procedure. Conclusions: A hybrid strategy of surgical ablation combined with intramural ethanol injection is feasible and effective in patients with multiple failed percutaneous ablation attempts.