Advances in Catheter Ablation of Ventricular Tachycardia: Technical Considerations and Contemporary Approaches

Ventricular tachycardia (VT) is a life-threatening arrhythmia that most commonly arises from reentrant circuits within myocardial scar in patients with structural heart disease. Although implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death, these devices do not prevent VT and are associated with significant physical and psychological burdens, while antiarrhythmic drug therapy is often limited by incomplete efficacy and adverse effects. These limitations have driven the increasing use of catheter ablation to target arrhythmogenic substrates. This review examines the evolving role of catheter ablation in VT management, including the supporting evidence, patient selection, procedural timing, and contemporary mapping and ablation strategies, drawing on data from randomized clinical trials, observational studies, and recent technological advances. Multiple trials, including SMASH-VT, VTACH, VANISH, SURVIVE-VT, and VANISH-2, have shown that catheter ablation reduces VT recurrence and ICD therapies, with growing evidence supporting the earlier or even first-line use of this technique in selected patients. Substrate-based ablation has become the cornerstone of modern practice, enabling effective treatment during sinus rhythm; meanwhile, preprocedural imaging, such as cardiac magnetic resonance and computed tomography, enhances scar characterization and procedural planning. Advanced approaches, including epicardial ablation, bipolar and needle ablation, and alternative energy delivery techniques, help overcome the limitations of conventional endocardial radiofrequency lesions. Emerging modalities, such as pulsed field ablation, show promise but require further validation. Despite these advances, VT-free survival remains approximately 50-60%, reflecting the complexity of the underlying arrhythmogenic substrates. Overall, catheter ablation has become an integral component of contemporary VT management, offering meaningful reductions in arrhythmia burden and ICD therapies, with increasing use earlier in the disease course; meanwhile, ongoing innovations in mapping, imaging integration, and energy delivery are expected to improve outcomes further, pending continued investigation into optimal patient selection, procedural timing, and long-term efficacy.