Multicenter analysis of catheter ablation of ventricular tachycardia in end-stage heart failure patients awaiting heart transplantation

Background Ventricular Tachycardia (VT), often recurrent or refractory, in patients with advanced Heart Failure (HF) listed for Heart Transplantation (HTx) is a predictor of high mortality and morbidity. These frail patients often require urgent HTx up-listing or Mechanical Circulatory Support (MCS). Current management relies on anti-arrhythmic drugs and Implantable Cardioverter-Defibrillators (ICDs), but repeated shocks worsen ventricular dysfunction. Catheter Ablation (CA) is a promising strategy to stabilize the arrhythmic substrate, but it's impact on HTx outcomes in this critical cohort is largely unexplored. This multi-center study aimed to evaluate the comparative efficacy of CA versus Optimal Anti-arrhythmic and Medical Therapy (MT) in controlling VT recurrence and reducing adverse events, including the need for HTx. Methods In this retrospective, multi-center study, we evaluated end-stage HF patients eligible for HTx with an ICD who had experienced at least two VT episodes requiring ICD shock therapy. Patients were managed with either CA (CA Group, n=40) or MT (MT Group, n=27). Primary endpoints were VT recurrence, HF hospitalization, and the need for HTx. Secondary endpoints included length of in-hospital stay and all-cause death. Results A total of 67 patients were retrospectively enrolled from January 2022 to March 2025, with a median follow-up of 1.7 years. Following multidisciplinary evaluation, 40 patients (60%) underwent CA, while 27 patients (40%) received optimal MT. Baseline characteristics were comparable between CA and MT groups. CA-treated patients demonstrated lower VT recurrence (13 vs. 17, p = 0.011 Fig. 1), a lower need for HTx (10 vs. 19, p < 0.01 Fig. 2) and a lower length of in-hospital stay (25 ± 18 vs. 62 ± 32 days, p < 0.01). No statistically significant differences were observed between the groups regarding HF hospitalization (10 vs 10, p = 0.290) and all-cause death (4 vs. 6, p = 0. 168). The CA group reported a total procedural complication rate of 12% (minor and major events). Conclusion Our results demonstrate that CA is a safe therapeutic option with an acceptable procedural complication rate and is associated with a significant improvement in several outcomes. The substantial reduction in VA recurrence and, notably, the decreased need for HTx suggest that CA can interrupt the pro-arrhythmic and heart failure spiral that often leads to urgent up-listing or MCS requirement. A key methodological consideration is the retrospective nature of this study, where patients not undergoing CA were likely considered clinically unsuitable for the intervention, potentially representing a higher-risk cohort. Nevertheless, CA represents a pivotal strategy to optimize the management of high-risk patients awaiting transplantation, and should be considered early as an integral part of the multidisciplinary approach in this critical clinical cohort.