Long-term outcomes of electrical storm patients listed for urgent heart transplantation but not transplanted acutely.

Aims: Refractory electrical storm (ES) is a life-threatening condition in which heart transplantation (HTx) can be proposed. Nevertheless, the shortage of donors and subsequent outcomes question its place as a rescue strategy. We aim to describe the prognosis of ES patients listed for HTx but not transplanted.

Methods and results: Patients registered on urgent HTx waiting list for refractory ES without being transplanted during initial hospitalization were retrospectively included in five French centres from 2010 to 2022. The primary endpoint was 1-year all-cause mortality. Forty patients were included [90% men; 56.5 (50.0-61.3) years old; 63.6% and 24.2% dilated and ischaemic cardiomyopathies]. Among them, 84.6% received amiodarone, 64.1% received beta-blockers; 50.0% required deep sedation, 35.0% mechanical circulatory support, 10.0% stellate ganglion block; and 57.5% underwent catheter ablation. At 1 year, 20 patients (50.0%) died, including 14 in-hospital deaths (35.0%). Within six patients who died post-discharge, four previously underwent HTx, and one received VAD implantation. Twenty patients (50.0%) were still alive at 1 year: 10 underwent HTx, 1 received VAD implantation followed by subsequent HTx, while another underwent VAD implantation as destination therapy. Finally, five (12.5%) were removed from the HTx waiting list due to functional improvement, distinguished by a median LVEF of 45.0% (20.0%-45.0%). The remaining three patients (7.5%) were still registered on HTx waiting list.

Conclusions: Refractory ES is a critical condition with high short- and long-term mortality. While HTx serves as a rescue strategy, rhythm management can sometimes overcome the critical phase, facilitating subsequent HTx under more favourable conditions or even allowing removal from the HTx waiting list.