Sabbir Ahmed, Khalid Sawalha, Mohamed Sharief, Ahmed Ammar
Advanced cardiac imaging can characterize infarct substrate and guide ablation strategy and lesion delivery during ventricular tachycardia (VT) ablation, but its incremental benefit over conventional strategies in ischemic cardiomyopathy (ICM) remains uncertain. We compared imaging-guided with conventional VT ablation in adults with ICM. This PRISMA-compliant systematic review and meta-analysis was registered in PROSPERO (CRD420261399180). MEDLINE, Cochrane CENTRAL, and Scopus were searched from January 1, 2016, through May 21, 2026, with citation tracking. Comparative analyses were restricted to ICM populations or extractable ICM subgroups. The primary outcome was VT recurrence, pooled using random-effects risk ratios (RRs); single-arm imaging-guided cohorts were summarized descriptively. Four comparative studies included 316 patients, of whom 134 underwent imaging-guided ablation and 182 underwent conventional ablation. Imaging-guided ablation was associated with lower VT recurrence (pooled RR 0.53, 95% confidence interval 0.36-0.79; p = 0.002; I 2 = 0%), with consistent effects across imaging modalities and study designs. Major complications were infrequent and numerically similar between groups, although sparse events and heterogeneous definitions precluded pooling. Three additional single-arm imaging-guided studies reported favorable VT-free or event-free survival, acceptable safety, and high acute non-inducibility, but were not used to infer comparative efficacy. In patients with ICM undergoing scar-related VT ablation, imaging-guided ablation was associated with lower VT recurrence without an apparent increase in major complications; given the limited comparative evidence, these findings are hypothesis-generating rather than practice-changing. Larger multicenter randomized trials are required to confirm the magnitude of benefit and define patient selection, imaging modality, and integration strategy.