Is Idiopathic Ventricular Tachycardia a Misnomer?

Abstract Purpose of Review To evaluate whether “idiopathic ventricular tachycardia” remains an appropriate label in the modern era. We synthesize current literature and review sites of origin, mechanisms, and characteristic ECG signatures, and appraise contemporary diagnostic approaches capable of revealing occult substrate. Recent Findings Tools such as cardiac MRI with late gadolinium enhancement and electroanatomic mapping frequently reveals substrate in patients once considered “idiopathic.” 18F-FDG PET-CT can also detect active myocardial inflammation when CMR is nondiagnostic, and high-density voltage mapping may expose low-voltage scar below imaging resolution. Early genetic signals (e.g., CCR7, PKN2) suggest heritable underpinnings for some “idiopathic” presentations. Summary A substantial fraction of “idiopathic” VT appears to reflect limitations in detection rather than true absence of disease. A pragmatic workup includes history/ECG, ischemia evaluation, CMR (LGE ± T1/T2 mapping), targeted inflammatory imaging when suspicion is high, and consideration of high-density voltage mapping in select cases. Standardized definitions incorporating modern diagnostics and long-term follow-up are needed.