Patient-Tailored Minimally Invasive Hybrid Ablation of Complex Ventricular Tachycardia Substrates

Clinical experience with minimally invasive hybrid ventricular tachycardia (VT) ablation remains limited, particularly regarding video-assisted thoracoscopic access.

The purpose of this study was to describe procedural characteristics, feasibility, and outcomes of minimally invasive hybrid VT ablation for complex substrates.

Consecutive patients undergoing minimally invasive hybrid VT ablation at a single tertiary center (2014-2025) were retrospectively analyzed. Multidisciplinary preprocedural evaluation was consistently performed, and from 2022 onward, this was formalized within the VT-TRACT (Ventricular Tachyarrhythmias: A Multidisciplinary Clinical-Translational Approach) care pathway.

In total, 22 patients (86% men, median age 70 years, median PAINESD score 13, 68% VT storm) underwent minimally invasive hybrid VT ablation: left- or right-sided video-assisted thoracoscopic (n = 13 vs 1), subxiphoid access (n = 3), double access (n = 2), and anterolateral minithoracotomy (n = 3). Indications were prior cardiac surgery in 7 (32%), extensive scar in 3 (14%), concomitant left-sided sympathectomy in 2 (9%), hybrid atrial fibrillation ablation in 1 (5%), failed epicardial access in 2 (9%), and pericarditis/tamponade in 2 (9%), while 5 (23%) underwent ablation under direct visualization by preference. Pericardial adhesions (45%) were bluntly dissected. Mean procedure time was 312 ± 98 minutes. At 1 year, median VT burden decreased from 16.5 (Q1-Q3: 9.5-37.0) to 0 (Q1-Q3: 0-5.8) (-81%; P < 0.001), and ICD shocks from 2 (Q1-Q3: 0-5) to 0 (Q1-Q3: 0-0) (-90%; P < 0.001). One hemothorax required reoperation; no other major complications occurred. One-year survival was 82%.

Minimally invasive, patient-tailored hybrid VT ablation-guided by multidisciplinary planning-achieves marked reductions in VT burden and ICD shocks with a favorable safety profile, even in complex post-surgical patients.