A 70-year-old man with severe ischemic cardiomyopathy (EF 25%) has recurrent ventricular tachycardia despite optimal medical therapy and ICD placement. Cardiac MRI shows a large anteroseptal scar with viable myocardium in the lateral and inferior walls. He has three-vessel coronary disease. His daughter is advocating for heart transplantation, but he has multiple comorbidities including obesity (BMI 37) and active tobacco use. Evaluate the management priority and rationale.
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