"From Surface to Substrate: Advancing VT Ablation Strategies for Deep Arrhythmic Substrates"-A Review of Emerging Techniques in Intramural Lesion Formation.

Intramural ventricular tachycardia represents a formidable frontier in catheter ablation, where the arrhythmogenic substrate resides deep within the myocardial wall, often beyond the reach of conventional energy delivery. Achieving durable lesion formation in this setting requires a strategic balance between transmural efficacy and procedural safety. This review synthesizes the evolving landscape of intramural ventricular tachycardia ablation, detailing contemporary techniques, including bipolar ablation, needle-based approaches, simultaneous endocardial-epicardial delivery, and emerging energy modalities, each tailored to overcome the limitations of lesion depth and tissue heterogeneity. We examine diagnostic criteria, imaging adjuncts, and electroanatomic mapping strategies that guide procedural planning and highlight innovations aimed at enhancing lesion depth without compromising adjacent structures. By integrating current evidence and expert practice, this article offers a comprehensive framework for navigating the complexities of intramural ventricular tachycardia ablation and advancing outcomes in this challenging domain.