Veno-Arterial Extracorporeal Membrane Oxygenation in High-Risk Ventricular Tachycardia Ablation: Current Evidence, Patient Selection, and Perioperative Management.

Catheter ablation is an established therapy for recurrent ventricular tachycardia (VT), but in patients with advanced structural heart disease, procedural success is often limited by acute hemodynamic decompensation during arrhythmia induction and mapping. Temporary mechanical circulatory support may improve procedural tolerance in selected high-risk cases. Among available devices, venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive support by combining biventricular circulatory assistance with gas exchange independent of native cardiac output, albeit at the cost of greater invasiveness and device-related morbidity.This narrative review summarizes the contemporary role of VA-ECMO in high-risk VT ablation, with emphasis on patient selection, comparative support strategies, periprocedural management, and outcomes. Available evidence, derived primarily from observational studies and small registries, suggests that VA-ECMO improves procedural feasibility by preserving systemic perfusion during sustained VT, repeated cardioversion, and prolonged activation mapping; however, current data do not support its routine use over less invasive modalities. In patients with isolated left ventricular dysfunction and preserved right ventricular reserve, an intra-aortic balloon pump or microaxial support may provide a more favorable balance between hemodynamic benefit and procedural risk, particularly when paired with planned access for rapid escalation. In contrast, VA-ECMO appears to be most appropriate in selected patients with severe biventricular dysfunction, refractory electrical storm, cardiogenic shock, severe gas exchange abnormalities, or profound intolerance to sustained VT. Preemptive and structured provisional strategies may provide greater procedural stability compared to rescue support initiated after hemodynamic collapse. Despite favorable rates of acute arrhythmia control, current evidence does not demonstrate a clear survival benefit.