ABSTRACTWe have previously reported the use of an epicardial approach for ablation of left ventricular, free wall accessory atrioventricular pathways. The technique involves mobilization of the atrioventricular fat pad and exposure and cryoablation of the atrioventricular junction at the site of the accessory pathway on the normothermic beating heart. Here we describe our further experience with left ventricular free wall accessory pathways and right ventricular free wall accessory pathways. Our experience is based on 53 consecutive patients. There were 35 male and 18 female subjects, 6 to 52 (mean 41.4) years old. Forty-eight patients had a left ventricular free wall accessory pathway, and five had a right ventricular free wall accessory pathway. Two patients had an associated anterior septal accessory pathway. Five patients had associated cardiac abnormalities, including atrial septal defect, aortic insufficiency, mitral valve prolapse, Ebstein's anomaly, and cardiomyopathy. The accessory pathway was ablated in 52 patients who remain arrhythmia free without medication after a mean follow-up period of 12 months. The accessory pathway was permanently modified in one patient. There were no postoperative complications. This epicardial approach can be performed with normothermic cardiopulmonary bypass or without bypass. It does not require cross-clamping of the aorta, allowing a greater margin of safety when this is required for concomitant procedures.