Heart transplantation in electrical storm and refractory ventricular arrhythmia patients
R Rakza, R P MartinsAbstract
Background
Electrical storm (ES) is a severe arrhythmic emergency associated with high short-term mortality. When unresponsive to medical therapy, ablation, or support devices, urgent heart transplantation (HTx) may be the only curative option. In France, an expert-reviewed transplantation allocation exists for refractory ventricular ablation (VA), but contemporary data on these high-urgency patients remain scarce.
Methods
We performed a retrospective analysis of prospectively collected registry data, including all adult HTx in France between 2018 and 2025 across 21 centers. Patients transplanted under the "life-threatening VA" exception were classified as the ES-HTx group. Baseline characteristics, acute arrhythmia management, and outcomes were analyzed. The primary endpoint was one-year all-cause mortality after propensity score matching; secondary endpoints were five-year survival, ablation trends, and determinants of post-HTx prognosis using univariate Cox.
Results
Among 2,891 HTx recipients, 141 (4.9%) were transplanted for ES. Compared with standard HTx, ES-HTx patients were older (median 57 vs 52 years), predominantly male (85%), and presented with higher LVEF (25% vs 20%) but less systemic congestion. The index arrhythmia was most often monomorphic VT (50%), with nearly all patients receiving amiodarone (84%) and adjunctive β-blockers (64%) or lidocaine (42%). Acute ablation was attempted in 29%, with rates rising steadily during the study period. Advanced supports were used including inotropes (20%) and ECLS (9%). At 12 months, survival was 75.2% in ES-HTx versus 79.3% in standard HTx (HR 1.04, 95% CI 0.68-1.60; p = 0.84). Outcomes remained similar at 5 years (72.0% vs 69.1%). Mortality was predominantly early and driven by infection and multiorgan failure. In univariate analysis, classical predictors of mortality (bilirubin, creatinine, BMI) remained significant, whereas arrhythmic features and etiology did not independently affect prognosis.
Conclusion
HTx for ES is feasible and yields survival comparable to standard indications, supporting its role as a legitimate therapeutic option when other therapeutic options are not feasible or have failed. Ablation remains underutilized before HTx but is increasingly performed, reflecting evolving practice. Early referral and timely escalation are essential to bridge patients to transplantation, while prospective studies are needed to refine candidate selection and optimize integration of adjunctive therapies