Rethinking VT Ablation in Severe Left Ventricular Dysfunction: Looking Beyond Ejection Fraction

E. Waezsada (Bad Oeynhausen)¹, M. Khalaph (Bad Oeynhausen)², N. Trajkovska (Bad Oeynhausen)¹, P. Lucas (Bad Oeynhausen)¹, V. Sciacca (Bad Oeynhausen)¹, T. Fink (Bad Oeynhausen)¹, E. Akkaya (Siegen)³, M. Mörsdorf (Bad Oeynhausen)¹, M. El Hamriti (Wetzikon)⁴, G. Imnadze (Neuruppin)⁵, D. Guckel (Bad Oeynhausen)¹, C. Sohns (Bad Oeynhausen)¹, P. Sommer (Bad Oeynhausen)¹, A. Darma (Bad Oeynhausen)^6
1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; ²Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland; ³Diakonie Klinikum Jung Stilling Innere Medizin Siegen, Deutschland; ⁴GZO Spital Wetzikon Klinik für Kardiologie und Angiologie Wetzikon, Schweiz; ⁵Universitätsklinikum Ruppin-Brandenburg Med. Klinik A Schwerpunkt Kardiologie Neuruppin, Deutschland; ⁶Herz- und Diabeteszentrum NRW Diabeteszentrum Bad Oeynhausen, Deutschland

Background:
Catheter ablation is an established treatment for ventricular tachycardia (VT) in structural heart disease (SHD). However, the clinical benefit of VT ablation in patients with severely reduced left ventricular ejection fraction (LVEF) remains uncertain.

Objective:
To determine whether severe LV dysfunction differentially affects arrhythmia-related and clinical outcomes after VT ablation.

Methods:
A total of 334 patients with SHD undergoing VT ablation were retrospectively included and stratified according to LVEF (≤25% vs 25–40%). Acute procedural outcomes, arrhythmic outcomes, and adverse clinical events during follow-up were assessed. The primary composite endpoint included appropriate ICD shocks, electrical storm after ablation, and repeat ablation, whereas the secondary composite endpoint comprised left ventricular assist device implantation (LVAD), heart transplantation (HTx), and death. An exploratory composite HF severity approach based on LVEF ≤25%, NYHA III–IV, and severe renal dysfunction was additionally evaluated.

Results:
Patients with LVEF ≤25% more frequently exhibited severe renal dysfunction, advanced HF symptoms, and larger LV dimensions. Acute procedural outcomes and arrhythmia-related outcomes were comparable between groups. VT recurrence rates were similar (31% vs 25%, p=0.268), and LVEF ≤25% was not independently associated with the primary endpoint (HR 1.02, 95% CI 0.64–1.65; p=0.92). In contrast, HF hospitalization (40% vs 23%, p=0.001) and LVAD/HTx/death (32% vs 14%, p<0.001) occurred more frequently in the LVEF ≤25% group. The more advanced HF group identified patients at increased risk for adverse clinical outcomes without significant differences in arrhythmia-related endpoints. Across the entire cohort, post-ablation arrhythmia recurrence was associated with worse prognosis.

Conclusion:
Severely reduced LVEF was associated with worse HF-related clinical outcomes despite preserved arrhythmia-related benefit after VT ablation. These findings suggest that VT ablation efficacy and underlying HF burden should be considered complementary determinants of post-ablation outcomes.

 

 

Key words: structural heart disease, severe heart failure, ventricular tachycardia, catheter ablation, VT recurrence, HTX, LVAD