Baseline clinical risk and procedural success after electrical storm ablation: Is high PAINESD score a marker of futility?

Background The PAINESD score is widely used to estimate peri-procedural mortality in patients undergoing ventricular tachycardia (VT) ablation. In electrical storm (ES), a high baseline risk may raise concerns regarding procedural futility. Whether elevated PAINESD scores are associated with lower technical success or diminished survival benefit remains uncertain. Purpose To evaluate the relationship between baseline PAINESD class and acute procedural success, and to assess short- and mid-term mortality according to procedural outcome across risk strata. Methods We analyzed 101 consecutive patients undergoing radiofrequency catheter ablation for drug-refractory ES. Patients were stratified according to PAINESD class (I-III). Acute complete success was defined as the non-inducibility of any sustained monomorphic VT during aggressive programmed ventricular stimulation with 4 extra stimuli at the end of the procedure. Primary endpoints were 30-day and 1-year all-cause mortality. Results The cohort was predominantly male with severely reduced left ventricular function. Acute complete procedural success was achieved in 80 patients (79.2%). Success rates across PAINESD classes were: Class I 85.7%, Class II 86.8%, and Class III 69.0%, without statistically significant differences (p=0.104). At 30 days, overall mortality was 4.0% (4/101). Mortality was numerically higher among patients without acute procedural success compared with those achieving non-inducibility (9.5% vs 2.5%), although this difference did not reach statistical significance (p=0.142) (Figures 1-2). At 1-year follow-up, overall mortality was 8.9%. Patients without acute procedural success had higher mortality compared with those achieving complete non-inducibility (19.0% vs 6.3%). In high-risk patients (PAINESD Class III), 1-year mortality was 23.1% in patients without procedural success versus 13.8% in those with successful ablation. Conclusion In our ES cohort, higher PAINESD risk was not significantly associated with lower procedural success. These findings suggest that elevated baseline clinical risk should not automatically be interpreted as procedural futility; however, procedural success does not completely mitigate underlying risk, and larger studies are warranted.