Guideline-directed device therapy (GDDT) for long QT syndrome (LQTS) has evolved over the years and indications for an implantable cardioverter defibrillator (ICD) vary amongst professional cardiac societies. To identify the subset of patients with LQTS who satisfied a class I or class II 2022 European Society of Cardiology (ESC) guideline-based recommendation for an ICD and determine the outcomes among those patients who received an ICD compared to those treated without an ICD. Retrospective analysis of 2,861 patients with either LQT1, LQT2 or LQT3 to identify patients meeting contemporary recommendations for GDDT. Basic demographics, clinical characteristics, and frequency/type of breakthrough cardiac events (BCEs) were extracted, and outcomes/complications were compared between patients treated with an ICD compared to those treated without one. Among the 290 patients (approximately 10%) who met a guideline-based recommendation, 53 (18%) satisfied a Class I/level B indication for an ICD, 56 (19%) a Class I/level C indication, 19 (7%) a Class IIA/level C indication, and 165 (55%) a Class IIB/level B indication. However, the majority 156/290 (54%) did not receive an ICD. Among those who received an ICD, 55/134 (41%) experienced ≥ 1 appropriate ventricular fibrillation (VF)-terminating ICD therapy while ICD-related complications occurred in 13 patients (10%). Of those who were treated without an ICD, only 6/154 patients (4%) had non-lethal BCEs, which was significantly lower compared to the ICD group (p<0.001). With over 1200 years of combined follow-up, the experience and evidence from our two LQTS specialty centers suggests that many patients who satisfy a recommendation for an ICD based upon the latest 2022 ESC Guidelines may not need one. This is particularly true when the indication stemmed from a BCE while on BB therapy or in asymptomatic patients with an increased '1-2-3 LQTS risk score'.