Catheter Ablation for Ventricular Tachycardias: Current Status and Future Perspectives

Catheter ablation for ventricular tachycardia (VT) in patients with systolic heart failure remains a critical yet challenging area of non-pharmacological therapy. Despite positive outcomes in atrial fibrillation, evidence for the efficacy of VT ablation in reducing cardiac mortality is inconclusive due to the absence of standardized ablation strategies. The primary challenges include difficulties in identifying suitable ablation targets and their deep locations within myocardial tissue. Current techniques, such as voltage mapping, provide valuable insights; however, they are limited by the presence of numerous bystander areas and the occurrence of incomplete transmural scarring. Recent advancements in functional substrate mapping have focused on identifying critical isthmuses without requiring hemodynamic stabilization during VT, thereby shifting the emphasis to the analysis of potentials during baseline rhythm. While methods like isochronal late activation mapping have improved target identification, they primarily address conduction abnormalities without adequately considering repolarization heterogeneity. This review highlights emerging technologies that utilize unipolar potentials to assess repolarization heterogeneities and identify VT isthmuses. Furthermore, novel ablation sources such as pulsed-field ablation, bipolar ablation, and ultra-low temperature cryoablation are being explored to create deeper and more durable lesions, addressing the limitations of traditional radiofrequency ablation. These advancements aim to reduce VT recurrence and improve overall treatment efficacy. Ultimately, understanding these innovative strategies is expected to optimize procedural outcomes and significantly enhance the management of patients with scar-related VT.