journal article·2026-03-14Open access

Current Evidence and Future Directions for Cardiac Imaging in Ventricular Tachycardia Ablation: A Narrative Review

Giovanni Canino, Assunta Di Costanzo, Nadia Salerno, Isabella Leo, Danilo Arnone, Patrizia Vizza, Giuseppe Tradigo, Pietro Hiram Guzzi, Daniele Torella, Pierangelo Veltri

Applied Sciences· Volume 16· Issue 6

Abstract

Management of ventricular tachycardia (VT) requires an integrated approach combining invasive therapy and cardiac imaging. This article reviews the principal imaging modalities and their integration with electroanatomical mapping systems to plan and guide procedures and to assess the success of VT ablation during follow-up. The central role of imaging in optimizing the efficacy and safety of VT ablation is emphasized. Studies demonstrating that imaging-supported workflows can improve substrate localization, reduce procedural times and radiation exposure, and lower recurrence rates are highlighted. Current limitations and future challenges are also discussed.
Source: crossref · Quality: baseline

Research context

OpenAlex topics: Cardiac Arrhythmias and Treatments · Atrial Fibrillation Management and Outcomes · Cardiac pacing and defibrillation studies

SciVX discovery tags are terminology-based. OpenAlex topics are source-provided classifications.

Affiliations

Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy

Department of Surgical and Medical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy

Department of Informatics, Modelling and Systems, University of Calabria, 87030 Rende, Italy

Cardiology Unit, AOU Dulbecco, 88100 Catanzaro, Italy

Funding

PNRR project FAIR—Future AI Research · Spoke 9—Green-aware AI, under the NRRP MUR program

References (100+)

Show source-provided references
1. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death10.1093/eurheartj/ehac262 ↗
2. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias10.1093/europace/euz132 ↗
3. Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs10.1056/NEJMoa1513614 ↗
4. Imaging to facilitate ventricular tachycardia ablation: Intracardiac echocardiography, computed tomography, magnetic resonance, and positron emission tomography10.1016/j.jacep.2024.08.003 ↗
5. Pre-procedural image-guided versus non-image-guided ventricular tachycardia ablation-a review10.1007/s12471-020-01485-z ↗
6. Outcomes of ventricular tachycardia ablation facilitated by pre-procedural cardiac imaging-derived scar characterization: A prospective multi-centre international registry10.1093/europace/euaf051 ↗
7. Lilli, A., Parollo, M., Mazzocchetti, L., De Sensi, F., Rossi, A., Notarstefano, P., Santoro, A., Aquaro, G.D., Cresti, A., and Lapira, F. (2022). Ventricular tachycardia ablation guided or aided by scar characterization with cardiac magnetic resonance: Rationale and design of VOYAGE study. BMC Cardiovasc. Disord., 22.10.1186/s12872-022-02581-1 ↗
8. Cardiac magnetic resonance-guided ventricular tachycardia substrate ablation10.1016/j.jacep.2019.11.004 ↗
9. Image-guided ablation of scar-related ventricular tachycardia: Towards a shorter and more predictable procedure10.1007/s10840-019-00686-w ↗
10. Di Cori, A., Pistelli, L., Parollo, M., Zaurino, N., Segreti, L., and Zucchelli, G. (2024). Approaching ventricular tachycardia ablation in 2024: An update on mapping and ablation strategies, timing, and future directions. J. Clin. Med., 13.10.3390/jcm13175017 ↗
11. Transthoracic echocardiography: Beginner’s guide with emphasis on blind spots as identified with CT and MRI10.1148/rg.2021200142 ↗
12. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging10.1016/j.echo.2014.10.003 ↗
13. Histopathological characterization of radiofrequency ablation in ventricular scar tissue10.1016/j.jacep.2019.05.011 ↗
14. Catheter ablation of ventricular tachycardia in patients with structural heart disease using cooled radiofrequency energy10.1016/S0735-1097(00)00615-X ↗
15. Long-term results after ablation of infarct-related ventricular tachycardia10.1016/j.hrthm.2005.01.017 ↗
16. Long-term clinical outcome of patients with prior myocardial infarction after palliative radiofrequency catheter ablation for frequent ventricular tachycardia10.1016/S0002-9149(01)01432-1 ↗
17. Acute hemodynamic decompensation during catheter ablation of scar-related ventricular tachycardia: Incidence, predictors, and impact on mortality10.1161/CIRCEP.114.002155 ↗
18. Early mortality after catheter ablation of ventricular tachycardia in patients with structural heart disease10.1016/j.jacc.2017.02.044 ↗
19. Effect of radiofrequency catheter ablation of ventricular tachycardia on left ventricular function in patients with prior myocardial infarction10.1023/A:1021341508720 ↗
20. Impact of catheter ablation for ventricular tachycardia on left ventricular ejection fraction in patients with structural heart disease10.1002/joa3.70042 ↗
21. Cardiac function after catheter ablation of ventricular arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy10.1093/ehjopen/oeaf049 ↗
22. Relative prognostic importance of left and right ventricular ejection fraction in patients with cardiac diseases10.1016/j.echo.2019.06.009 ↗
23. Transthoracic 3D echocardiography used as a low-cost and precise technique to facilitate ablation of ventricular tachycardia from the left posteromedial papillary muscle
24. Mirzeyeva, G., Heukäufer, M., Janschel, S., Schneppe, D., Ebrahimi, R., Dörr, M., Kiuchi, M.G., Futyma, P., Martinek, M., and Pürerfellner, H. (2024). 3D map combined with transthoracic echocardiography for ablation of premature ventricular contractions/ventricular arrhythmia from papillary muscle: A technical report. J. Clin. Med., 13.10.3390/jcm13216358 ↗
25. Mechanical dispersion assessed by myocardial strain in patients after myocardial infarction for risk prediction of ventricular arrhythmia10.1016/j.jcmg.2009.11.012 ↗
26. Speckle-tracking echocardiography parameters associated with ventricular arrhythmia recurrence-free survival after ablation in structural heart disease10.1016/j.echo.2025.05.004 ↗
27. Global longitudinal strain as a predictor of first and subsequent arrhythmic events in remotely monitored ICD patients with structural heart disease10.1016/j.jcmg.2018.12.020 ↗
28. Speckle-tracking strain echocardiography in the assessment of myocardial mechanics in patients with idiopathic ventricular arrhythmias: A longitudinal follow-up study10.1161/CIRCEP.120.008748 ↗
29. Longitudinal strain with speckle-tracking echocardiography predicts electroanatomic substrate for ventricular tachycardia in nonischemic cardiomyopathy patients10.1016/j.hroo.2022.02.002 ↗
30. Transesophageal echocardiography during radiofrequency catheter ablation of ventricular tachycardia10.1016/0002-9149(93)90880-L ↗
31. Image integration using intracardiac ultrasound and 3D reconstruction for scar mapping and ablation of ventricular tachycardia10.1111/j.1540-8167.2009.01680.x ↗
32. Intracardiac echo-facilitated 3D electroanatomical mapping of ventricular arrhythmias from the papillary muscles: Assessing the ‘fourth dimension’ during ablation10.1093/europace/euw099 ↗
33. Cryoablation for ventricular arrhythmias arising from the papillary muscles of the left ventricle guided by intracardiac echocardiography and image integration10.1016/j.jacep.2015.07.012 ↗
34. Results of cryoenergy and radiofrequency-based catheter ablation for treating ventricular arrhythmias arising from the papillary muscles of the left ventricle, guided by intracardiac echocardiography and image integration10.1161/CIRCEP.115.003874 ↗
35. Intracardiac echocardiography techniques to identify ventricular arrhythmia substrate10.1016/j.hroo.2022.06.006 ↗
36. Intracardiac echocardiography to guide catheter ablation of ventricular arrhythmias in ischemic cardiomyopathy10.1016/j.ccep.2021.02.002 ↗
37. Next-generation cardiac magnetic resonance imaging techniques for characterization of myocardial disease10.1007/s11936-024-01044-4 ↗
38. Cardiovascular imaging research and innovation in 202310.1093/ehjimp/qyae029 ↗
39. MRI-Guided ventricular tachycardia ablation: Integration of late gadolinium-enhanced 3D scar in patients with implantable cardioverter-defibrillators10.1161/CIRCEP.110.958744 ↗
40. Four gadolinium(III) complexes appended to a porphyrin: A water-soluble molecular theranostic agent with remarkable relaxivity suited for MRI tracking of the photosensitizer10.1021/acs.inorgchem.6b00381 ↗
41. Cardiac imaging in patients with ventricular tachycardia10.1161/CIRCULATIONAHA.117.029349 ↗
42. Standardized cardiovascular magnetic resonance imaging (CMR) protocols: 2020 update10.1186/s12968-020-00607-1 ↗
43. 3D delayed-enhanced magnetic resonance sequences improve conducting channel delineation prior to ventricular tachycardia ablation10.1093/europace/euu310 ↗
44. Motion-corrected free-breathing late gadolinium enhancement combined with a gadolinium contrast agent with a high relaxation rate: An optimized cardiovascular magnetic resonance examination protocol10.1177/0300060520964664 ↗
45. Full free-breathing cardiovascular magnetic resonance imaging: Enhancing efficiency and image quality in clinical practice10.1016/j.jocmr.2025.101955 ↗
46. Dark-blood late gadolinium enhancement cardiovascular magnetic resonance for improved detection of subendocardial scar: A review of current techniques10.1186/s12968-021-00777-6 ↗
47. Integration of 3D electroanatomic maps and magnetic resonance scar characterization into the navigation system to guide ventricular tachycardia ablation10.1161/CIRCEP.111.961946 ↗
48. Three-dimensional architecture of scar and conducting channels based on high resolution ce-CMR: Insights for ventricular tachycardia ablation10.1161/CIRCEP.113.000264 ↗
49. Optimizing ventricular tachycardia ablation through imaging-based assessment of arrhythmic substrate: A comprehensive review and roadmap for the future10.1016/j.hroo.2024.07.001 ↗
50. VT ablation based on CT imaging substrate visualization: Results from a large cohort of ischemic and non-ischemic cardiomyopathy patients
51. Epicardial ventricular arrhythmia ablation: A clinical consensus statement of the European Heart Rhythm Association of the European Society of Cardiology and the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society, the Latin American Heart Rhythm Society, and the Canadian Heart Rhythm Society10.1093/europace/euaf055 ↗
52. Correlation between functional substrate mapping and cardiac computed tomography-derived wall thinning for ventricular tachycardia ablation10.1016/j.jacep.2023.05.018 ↗
53. Quantitative analysis of late iodine enhancement using dual-layer spectral detector computed tomography: Comparison with magnetic resonance imaging10.21037/qims-21-344 ↗
54. Diagnostic accuracy of late iodine enhancement on cardiac CT for myocardial tissue characterization: A systematic review and meta-analysis10.1007/s00330-024-11283-5 ↗
55. van den Bruck, J.H., Schipper, J.H., Seuthe, K., Dittrich, S., Maximidou, T., Sultan, A., Ackmann, J., Wörmann, J., Scheurlen, C., and Lüker, J. (2025). Preprocedural substrate visualization and image integration based on late enhancement computed tomography for ventricular tachycardia ablation in non-ischemic cardiomyopathy. J. Clin. Med., 14.10.3390/jcm14165801 ↗
56. Lipomatous metaplasia enables Ventricular Tachycardia by reducing current loss within the protected corridor10.1016/j.jacep.2022.07.005 ↗
57. Lipomatous metaplasia facilitates slow conduction in critical Ventricular Tachycardia corridors within postinfarct myocardium10.1016/j.jacep.2023.02.014 ↗
58. Lipomatous metaplasia is associated with ventricular tachycardia recurrence following ablation in patients with nonischemic cardiomyopathy10.1016/j.jacep.2024.02.024 ↗
59. Imaging-aided VT ablation. Long-term results from a pilot study10.1111/jce.16741 ↗
60. Notarstefano, P., Ciabatti, M., Marallo, C., Lazzeri, M., Fraticelli, A., Tavanti, V., Zucchelli, G., La Camera, A., and Bolognese, L. (2025). The role of imaging in ventricular tachycardia ablation. Diagnostics, 15.10.20944/preprints202507.1216.v1 ↗
61. Epicardial ventricular tachycardia ablation: A contemporary review of indications, techniques, and practical approaches for challenging substrates10.31083/RCM44332 ↗
62. Iatrogenic acute coronary occlusion during epicardial ventricular tachycardia ablation: When intravascular imaging guides the management-a case report10.1093/ehjcr/ytaf358 ↗
63. Lameka, K., Farwell, M.D., and Ichise, M. (2016). Positron emission tomography. Handbook of Clinical Neurology, Elsevier.
64. Outcomes of catheter ablation in cardiac sarcoidosis patients with ventricular tachycardia: A propensity score-matched retrospective analysis10.1007/s10840-025-01986-0 ↗
65. Clinical outcomes after catheter ablation in cardiac sarcoidosis and idiopathic nonischemic cardiomyopathy10.1111/jce.16756 ↗
66. Integration of three-dimensional scar maps for ventricular tachycardia ablation with positron emission tomography-computed tomography10.1016/j.jcmg.2007.10.001 ↗
67. Integration of positron emission tomography/computed tomography with electroanatomical mapping: A novel approach for ablation of scar-related ventricular tachycardia10.1016/j.hrthm.2008.08.020 ↗
68. Metabolic scar assessment with18F-FDG PET: Correlation to ischemic ventricular tachycardia substrate and successful ablation sites10.2967/jnumed.120.246413 ↗
69. Integration of 3-dimensional scar models from SPECT to guide ventricular tachycardia ablation10.2967/jnumed.111.094904 ↗
70. Integration of 3D nuclear imaging in 3D mapping system for ventricular tachycardia ablation in patients with implanted devices: Perfusion/voltage retrospective assessment of scar location10.1016/j.hroo.2022.06.008 ↗
71. Three-dimensional 123I-meta-iodobenzylguanidine cardiac innervation maps to assess substrate and successful ablation sites for ventricular tachycardia: Feasibility study for a novel paradigm of innervation imaging10.1161/CIRCEP.114.002105 ↗
72. Substrate mapping for ventricular tachycardia: Assumptions and misconceptions10.1016/j.jacep.2015.09.001 ↗
73. Subramanian, M., Atreya, A.R., Saggu, D.K., Yalagudri, S., and Calambur, N. (2023). Catheter ablation of ventricular tachycardia: Strategies to improve outcomes. Front. Cardiovasc. Med., 10.10.3389/fcvm.2023.966634 ↗
74. Substrate-based approaches in ventricular tachycardia ablation10.1016/j.ipej.2022.08.002 ↗
75. Ventricular tachycardia substrate mapping: What’s been done and what needs to be done10.1016/j.hrthm.2025.02.034 ↗
76. Elimination of local abnormal ventricular activities: A new end point for substrate modification in patients with scar-related ventricular tachycardia10.1161/CIRCULATIONAHA.111.043216 ↗
77. Decrement evoked potential mapping: Basis of a mechanistic strategy for ventricular tachycardia ablation10.1161/CIRCEP.115.003083 ↗
78. Decrement evoked potential mapping to guide ventricular tachycardia ablation: Elucidating the functional substrate10.15420/aer.2020.25 ↗
79. An annotation-independent algorithm based on electrogram characteristics to guide the identification of ventricular tachycardia isthmuses in patients with structural heart disease10.1007/s10840-023-01657-y ↗
80. Acute and long-term results of bipolar radiofrequency catheter ablation of refractory ventricular arrhythmias of deep intramural origin10.1016/j.hrthm.2020.04.028 ↗
81. Preprocedural imaging to guide transcoronary ethanol ablation for refractory septal ventricular tachycardia10.1111/jce.13816 ↗
82. Image integration to guide catheter ablation in scar-related ventricular tachycardia10.1111/jce.12963 ↗
83. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: A clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology10.1093/europace/euae108 ↗
84. Inflammasome activation of cardiac fibroblasts is essential for myocardial ischemia/reperfusion injury10.1161/CIRCULATIONAHA.110.982777 ↗
85. The evolving medical complexity of the modern cardiac intensive care unit10.1016/j.jacc.2017.01.061 ↗
86. Preventive substrate ablation in chronic post-myocardial infarction patients with high-risk scar characteristics for ventricular arrhythmias: Rationale and design of PREVENT-VT study10.1007/s10840-022-01392-w ↗
87. Substrate mapping for unstable ventricular tachycardia10.1016/j.hrthm.2015.09.023 ↗
88. Impact of ICD artifact burden on late gadolinium enhancement cardiac MR imaging in patients undergoing ventricular tachycardia ablation10.1111/pace.12405 ↗
89. Predicting arrhythmia recurrence following catheter ablation for ventricular tachycardia using late gadolinium enhancement magnetic resonance imaging: Implications of varying scar ranges10.1016/j.hrthm.2022.05.021 ↗
90. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation10.1093/europace/euy040 ↗
91. Canino, G., Di Costanzo, A., Salerno, N., Leo, I., Cannataro, M., Guzzi, P.H., Veltri, P., Sorrentino, S., De Rosa, S., and Torella, D. (2025). Artificial intelligence in cardiac electrophysiology: A clinically oriented review with engineering primers. Bioengineering, 12.10.3390/bioengineering12101102 ↗
92. Dello Russo, A., Valeri, Y., Ciconte, G., Schiavone, M., Compagnucci, P., Di Monaco, A., Riva, S., Salerno, R., Volpato, G., and Cipolletta, L. (2025). AI-assisted 3D intracardiac echocardiography for Pulsed Field Ablation of atrial fibrillation using a novel variable loop circular catheter: A multicenter evaluation. J. Clin. Med., 14.10.3390/jcm14207249 ↗
93. Feasibility of three-dimensional artificial intelligence algorithm integration with intracardiac echocardiography for left atrial imaging during atrial fibrillation catheter ablation10.1093/europace/euad211 ↗
94. Feasibility of a novel algorithm for automated reconstruction of the left atrial anatomy based on intracardiac echocardiography10.1111/pace.14599 ↗
95. Machine learning approach for automated localization of ventricular tachycardia ablation targets from substrate maps: Development and validation in a porcine model10.1093/ehjdh/ztaf064 ↗
96. Preclinical experience using 4D intracardiac echocardiography to guide cardiac electrophysiology procedures10.1111/jce.16531 ↗
97. Digital twins: The future for ventricular tachycardia ablation?10.1161/CIRCULATIONAHA.124.072299 ↗
98. First-in-human real-time MR-guided ventricular ablation for idiopathic outflow tract premature ventricular complexes10.1001/jamacardio.2025.3000 ↗
99. Myocardial characterization using late enhancement photon-counting detector CT in ventricular arrhythmia: Comparison with electroanatomical mapping10.1186/s13244-025-02069-4 ↗
100. STRA-MI-VT (STereotactic RadioAblation by Multimodal Imaging for Ventricular Tachycardia): Rationale and design of an Italian experimental prospective study10.1007/s10840-020-00855-2 ↗