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

BACKGROUND: Clinical experience with minimally invasive hybrid ventricular tachycardia (VT) ablation remains limited, particularly regarding video-assisted thoracoscopic access. OBJECTIVES: The purpose of this study was to describe procedural characteristics, feasibility, and outcomes of minimally invasive hybrid VT ablation for complex substrates. METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.