Early catheter ablation in electrical storm: a propensity score-matched comparison with medical therapy

Background Electrical storm (ES) is a life-threatening arrhythmic emergency, whose initial management relies on antiarrhythmic therapy, beta-blockers, sedation, and hemodynamic support. Early catheter ablation (CA) has been proposed as a strategy to improve outcomes. This study aimed to compare CA with medical therapy alone in patients experiencing a first ES episode. Methods Single-center, retrospective study including consecutive patients admitted to the cardiac intensive care unit (CICU) between 2015 and 2025 with a first ES episode, defined as ≥3 episodes of sustained ventricular arrhythmia within 24 hours. Patients were categorized according to management strategy (medical therapy or CA performed during the index hospitalization) and subsequently matched 1:1 based on age, left ventricular ejection fraction (LVEF), PAINESD score, creatinine, NT-proBNP, presence of a trigger, and the use of sedation, mechanical ventilation, and vasoactive drugs. In the matched cohort, Cox regression was used to estimate hazard ratios (HRs) for time-to-event outcomes: ventricular tachycardia (VT) recurrence and cardiovascular (CV) mortality during follow-up (FUP). Results A total of 127 patients were included (age 65±14 years; 88% male): 69 (54%) underwent CA and 58 (46%) received medical therapy. The majority had ischemic structural heart disease (59%), followed by non-ischemic cardiomyopathy (39%); 88% presented with monomorphic VT. Patients managed medically presented more frequently with acute myocardial infarction (22% vs. 3%, p<0.001), out-of-hospital cardiac arrest (12% vs. 1%, p=0.023), and identifiable triggers (47% vs. 13%, p<0.001). During hospitalization, 33% required continuous sedation, 30% mechanical ventilation, and 26% vasoactive support. Compared with medical therapy, CA patients required less sedation (25% vs. 43%, p=0.044), mechanical ventilation (19% vs. 43%, p=0.005), and vasoactive drugs (17% vs. 36%, p=0.027), suggesting greater early clinical stability. Time to CA was 5 days [3-8], and hospital stay 11 days [6-20], with in-hospital mortality of 13%. After a median FUP of 2.1 years [0.4-3.5], CV mortality was 18% and VT recurrence was 29%. Before propensity score matching, CV mortality was lower among patients undergoing CA (9% vs. 29%, p=0.006) [Figure 1A], while VT recurrence rates were similar [Figure 1B]. After matching (34 matched pairs, n=68) [Figure 2], CA was associated with lower VT recurrence (HR 0.29, 95% CI 0.07-0.98, p=0.046) [Figure 1D], whereas CV mortality no longer differed significantly (HR 0.38, 95% CI 0.10-1.41, p=0.147) [Figure 1C]. Conclusion ES patients treated medically presented with greater clinical instability and higher early mortality, reflecting substantial baseline differences between groups. After matching, CA independently predicted lower VT recurrence, suggesting that CA reduces arrhythmic burden, although without evidence of a survival benefit.