Catheter Ablation of Ventricular Tachycardia in Patients Awaiting Heart Transplantation: Practice and Perspectives

Advanced Heart failure (adHF) is the final common pathway of multiple cardiovascular diseases and affects over 64 million people worldwide. Ventricular arrhythmias (VAs), including electrical storm, are part of the natural history of adHF, being associated with morbidity, mortality, and missing of effective therapeutic options. Management often requires intensive care, deep sedation, autonomic modulation, multiple antiarrhythmic drugs, and mechanical circulatory support (MCS), while non-responders have very limited alternatives. Heart transplantation (HTx) remains the gold standard therapy, although its availability is constrained by the lack of donors and strict allocation criteria. VAs are major drivers of urgent HTx listing across allocation systems. In recent years, catheter ablation (CA) has evolved into a disease-modifying therapy for scar-related VAs, with improvements in safety, mapping resolution, and procedural efficacy. Although randomized data in adHF populations remain limited, observational studies and contemporary trials demonstrate that CA can significantly reduce arrhythmic burden, implantable cardioverter-defibrillator shocks, hospitalizations, and the need for urgent HTx, particularly when performed early in the disease course. Advances in substrate-based strategies, functional mapping, multipolar and omnipolar technologies, and integration of cardiac imaging have enhanced procedural precision, while preprocedural risk stratification tools guide the use of MCS to improve safety in high-risk patients. Emerging therapies, including pulsed-field ablation, stereotactic arrhythmia radiotherapy, and autonomic modulation, alongside multimodal imaging, are expanding treatment options for refractory VAs in end-stage cardiomyopathy. This review provides a comprehensive state-of-the-art overview of VA mechanisms, patient selection, ablation strategies, and future directions in the management of severe VAs in adHF, with a focus on patients awaiting HTx.