Advancement in cardiac imaging for treatment of ventricular arrhythmias in structural heart disease

Over the last decades, substrate-based approaches to ventricular tachycardia (VT) ablation have evolved into an important therapeutic option for patients with various structural heart diseases (SHD) and unmappable VT. The well-recognized limitations of conventional electroanatomical mapping (EAM) to delineate the complex 3D architecture of scar, and the potential capability of advanced cardiac imaging technologies to provide adjunctive information, have stimulated electrophysiologists to evaluate the role of imaging to improve safety and efficacy of catheter ablation. In this review, we summarize the histological differences between SHD aetiologies related to monomorphic sustained VT and the currently available data on the histological validation of cardiac imaging modalities and EAM to delineate scar and the arrhythmogenic substrate. We review the current evidence of the value provided by cardiac imaging to facilitate VT ablation and to ultimately improve outcome.