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Life-threatening refractory unstable ventricular arrhythmias in presence of advanced heart failure (HF) may determine haemodynamic impairment. Haemodynamic mechanical support (HMS) in this setting has a relevant role to restore end-organ perfusion. Catheter ablation (CA) of ventricular tachycardia (VT) is effective at achieving rhythm stabilization, allowing patient's weaning from HMS, or bridging to permanent HF treatments. Acute heart decompensation during CA at anaesthesia induction in presence of advanced heart disease, in selected cases requires a preemptive HMS to prevent periprocedure adverse outcomes. Substrate ablation during sinus rhythm (SR) might be an effective strategy of ablation in presence of unstable VTs; however, in a minority of patients, it might have some limitations and might be unfeasible in some settings, including the case of the mechanical induction of several unstable VTs and the absence of ablation targets. In case of the persistent induction of unstable VTs after a previous failure of a substrate-based ablation in SR, a feasible alternative strategy of ablation might be VT activation/entrainment mapping supported by HMS. Multiple devices are available for HMS in the low-output states related to electrical storm and during CA of VT. The choice of the device is not standardized and it is based on the centres' expertise. The aim of this article is to provide an up-to-date review on HMS for the management of life-threatening arrhythmias, in the context of catheter ablation and discussing our approach to manage critical VT patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: We present clinical, electroanatomical mapping (EAM), imaging, and catheter ablation (CA) strategies in patients with myocarditis-related ventricular tachycardia (VT)., Methods and Results: Between January 2010 and July 2012, 26 consecutive patients underwent imaging-guided CA of myocarditis-related ventricular arrhythmias, 23 of 26 using a combined endo-epicardial approach. Segment per segment correspondence of late enhanced (LE) scar localization with EAM scar was assessed in all patients with available uni/bipolar maps (n = 19). Induced VTs were targeted prior to substrate modification. Late potentials (LPs) abolition constituted a procedural endpoint independently from VT inducibility. Clinical monomorphic VT was induced in 15 of 26 patients (57.7%) and was associated with epicardial LPs in 10 of 15, completely abolished in 7 of 10 patients. Of the 10 patients rendered non-inducible VTs were ablated epicardially in 7. Late potentials were also detected in 7 of 11 initially non-inducible patients and completely abolished in 4. After a median follow-up of 23 (15-31) months, 20 of 26 patients (76.9%) remained free from VT recurrence. Bipolar mapping revealed low-voltage scar (<1.5 mV) in 1 patient endocardially and in 14 of 19 epicardially. Unipolar mapping revealed low-voltage scar (<8 mV) in 12 of 19 patients endocardially and in 18 of 19 epicardially. Correspondence of LE scar localization with endocardial bipolar scar was 1%, with endocardial unipolar scar 23.7%, with epicardial bipolar scar 39.8%, and with epicardial unipolar scar 66.2%., Conclusion: Pre-procedural scar imaging and EAM findings support the necessity of an epicardial approach in patients with prior myocarditis. Epicardial unipolar mapping (<8 mV) is superior in scar identification and CA based on substrate modification is safe and effective in this setting., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Aims: Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a 'back-up' implantable cardioverter-defibrillator (ICD)., Methods and Results: One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%)., Conclusion: Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strategy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)