Beyond Electroanatomical Mapping: The Role of Cardiac Magnetic Resonance in Ventricular Tachycardia Ablation, A Systematic Review and Meta-analyses

Abstract Background Ventricular tachycardia (VT) ablation in patients with structural heart disease remains challenging because arrhythmogenic substrates may be intramural, septal, or epicardial and incompletely identified by conventional electroanatomical mapping. Cardiac magnetic resonance (CMR) may improve substrate characterization and procedural planning. This systematic review and meta-analysis evaluated procedural and long-term outcomes of CMR-informed VT ablation, including CMR-guided and CMR-aided approaches, compared with conventional non-CMR-guided ablation. Methods PubMed, MEDLINE via EBSCOhost, ScienceDirect, Scopus, and the Cochrane Library were searched on March 16, 2026, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Comparative studies evaluating CMR-informed versus non-CMR-guided VT ablation were included. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes as mean differences (MDs), with 95% confidence intervals (CIs), using random-effects models. CMR-guided and CMR-aided groups in multi-arm studies were combined to avoid double-counting shared controls. Results Three nonrandomized comparative studies comprising 339 patients were included. Complete procedural success was numerically more frequent with CMR-informed ablation, but the difference was not statistically significant and heterogeneity was substantial (RR 1.39, 95% CI 0.94–2.05; I²=85%). CMR-informed ablation was associated with lower residual VT inducibility after substrate ablation (RR 0.54, 95% CI 0.41–0.71; I²=0%) and fewer procedures ending in partial success (RR 0.46, 95% CI 0.30–0.71; I²=0%). No clear difference was observed in procedural failure (RR 0.66, 95% CI 0.23–1.93). Procedure duration, fluoroscopy time, and radiofrequency (RF) ablation time were not significantly different and showed moderate-to-substantial heterogeneity. CMR-informed ablation was associated with fewer RF applications (MD − 7.24, 95% CI − 11.88 to − 2.59; I²=0%). The pooled long-term analysis showed fewer reported events (RR 0.41, 95% CI 0.28–0.60; I²=0%); however, endpoint definitions differed because one study used a composite of VT recurrence, heart transplantation, or death. Conclusions CMR-informed VT ablation was associated with lower residual VT inducibility and fewer RF applications, while evidence for improved complete procedural success and shorter procedural duration remained inconclusive. The apparent reduction in long-term events should be interpreted cautiously because all included studies were observational, follow-up and endpoint definitions were inconsistent, and possible cohort overlap could not be excluded. Prospective, adequately powered studies using standardized CMR acquisition, integration, ablation, and follow-up protocols are required.