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

BackgroundClinical experience with minimally invasive hybrid ventricular tachycardia (VT) ablation remains limited, particularly regarding video-assisted thoracoscopic (VATS) access. ObjectivesTo describe procedural characteristics, feasibility, and outcomes of minimally invasive hybrid VT ablation for complex substrates. MethodsConsecutive 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. ResultsTwenty-two patients (86% male, median age 70 years, median PAINESD score 13, 68% VT storm) underwent minimally invasive hybrid VT ablation: left- or right-sided VATS (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%) and hybrid atrial fibrillation ablation in 1 (5%), failed epicardial access in 2 (9%), 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 one year, median VT burden decreased from 16.5 [9.5-37.0] to 0 [0-5.8] (-81%, P<0.001), and ICD shocks from 2 [0-5] to 0 [0-0] (-90%, P<0.001). One hemothorax required reoperation; no other major complications occurred. One-year survival was 82%. ConclusionsMinimally 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.