Invasive Assessment of Right Ventricular Dysfunction Predicts Periprocedural Outcomes in Patients Undergoing Unplanned Ventricular Tachycardia Ablation

BACKGROUND: Risk stratification in patients undergoing urgent ventricular tachycardia (VT) ablation is limited, particularly regarding right ventricular dysfunction, which is often underrecognized in this setting. OBJECTIVES: We investigated whether the right atrial pressure (RAP) to pulmonary capillary wedge pressure (PCWP) ratio or pulmonary artery pulsatility index (PAPi) predicts short-term outcomes following urgent VT ablation. METHODS: We retrospectively analyzed 102 consecutive patients who underwent unplanned inpatient VT ablation and had right heart catheterization (RHC) within the preceding 12 months. All were admitted with recurrent VT; 67 (66%) had VT storm. Hemodynamic stratification was performed using two established indices of right-sided function: RAP:PCWP > 0.6 versus ≤ 0.6 and pulmonary artery pulsatility index (PAPi) < 2 versus ≥ 2, calculated as (pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/right atrial pressure. Outcomes included acute kidney injury (AKI), intraprocedural hemodynamic instability, 30-day VT recurrence, 30-day mortality/LVAD/transplant, delayed extubation, postoperative length of stay > 7 days, and same-day complications. Multivariable logistic regression adjusted for age, sex, LVEF, NYHA class, ischemic cardiomyopathy, RHC type, and moderate-to-severe MR/TR. RESULTS: The cohort was 88% male, mean age 64 ± 11.9 years; 47% had LVEF < 25%, and 58% NYHA III-IV symptoms. RAP:PCWP > 0.6 was independently associated with higher risk of AKI (OR 10.4, 95% CI 2.4-14.1, p = 0.002) and intraprocedural hemodynamic instability (OR 6.1, 95% CI 1.5-16.3, p = 0.050). Age > 60 also predicted AKI (OR 12.8, 95% CI 1.3-21.3). PAPi < 2 and LVEF < 25% were not associated with adverse outcomes. CONCLUSION: Among urgent VT ablation patients, elevated RAP:PCWP, but not PAPi, identifies those at increased risk for AKI and intraprocedural hemodynamic instability. Incorporating RAP:PCWP into preprocedural assessment may enhance risk stratification.