Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper is devoted to an extremely urgent problem of modern cardiology and electrophysiology - optimization of treatment of ventricular tachycardia (VT) in patients with structural heart pathology. The high frequency of relapses, electrical storms, progression of heart failure and increased mortality necessitate improvement of approaches to catheter ablation.

In this context, the integration of multimodal imaging (CMR, CT, ICE, PET/SPECT) with electroanatomical mapping is a modern and promising direction, which corresponds to international trends in the development of personalized arrhythmology. Therefore, the topic of the article is timely, clinically significant and scientifically substantiated.

The work is more of a review and is aimed at:

• systematization of modern capabilities of multimodal cardiac imaging in VT ablation;
• analysis of the role of each technique (echocardiography, CMR-LGE, CT, LIE-CT, FDG-PET, SPECT);
• justification of integration with electroanatomical mapping (EAM);
• assessment of clinical effectiveness of imaging-facilitated workflows;
• identification of methodological limitations;
• outline of development prospects (AI, 4D-ICE, digital twins, real-time CMR, STAR).

Thus, the study is aimed at forming a conceptual model of an integrated imaging-guided approach to substrate ablation of ventricular tachycardia.

The scientific novelty of the work lies in:

• Systematic generalization of the current evidence base on imaging-guided and imaging-aided strategies.
• Clear distinction between the concepts of CMR-aided and CMR-guided ablation, which has methodological significance.
• Detailed analysis of PSI-maps (Pixel Signal Intensity) as a tool of a substrate-oriented strategy.
• Justification of the transition from static anatomical maps to predictive models ("digital twins").
• Critical analysis of the limitations of standardization of imaging–EAM integration.

The paper demonstrates a high level of scientific argumentation and a modern vision of the problem.

The practical significance of the work lies in the fact that:

• a clear algorithm for the role of imaging at the pre-, intra- and post-procedural stages is provided;
• parameters that can be used as standardized endpoints are summarized;
• the choice of imaging method is justified depending on the clinical scenario;
• the importance of integrating LGE-CMR and LIE-CT in access planning (endo/epicardial) is emphasized;
• data on the impact on the duration of the procedure, fluoroscopy and VT-free survival are provided.

The material is of practical value for cardiologists, electrophysiologists, medical imaging specialists and developers of EAM systems.

Remarks

1. Since the work is of a review nature, it would be advisable to indicate the criteria for searching the literature, the time frame and the principles for including studies to increase methodological transparency.
2. Although VT-free survival and procedure time reduction rates are reported, a generalized comparative table with a meta-analysis of key outcomes is lacking.
3. The paper mentions organizational and financial barriers, but lacks a cost-effectiveness analysis, which is critically important for the widespread implementation of imaging-guided strategies.

Overall conclusion

The paper is a thorough, structured, and scientifically sound work that systematizes modern approaches to multimodal imaging in ventricular tachycardia ablation and outlines the prospects for the development of imaging-guided electrophysiology.

Comments on the Quality of English Language

good

Author Response

Reviewer 1 Comment 1 Since the work is of a review nature, it would be advisable to indicate the criteria for searching the literature, the time frame and the principles for including studies to increase methodological transparency. ( prism diagram)

ANSWER: We added the methods section and a prisma diagram

 

Reviewer 1 Comment 2 Although VT-free survival and procedure time reduction rates are reported, a generalized comparative table with a meta-analysis of key outcomes is lacking. (Fare)

             ANSWER: We added TABLE 1 in the introduction

 

Reviewer 1 Comment 3 The paper mentions organizational and financial barriers, but lacks a cost-effectiveness analysis, which is critically important for the widespread implementation of imaging-guided strategies.

ANSWER: The section “Cost-effectiveness data” has been added.

Reviewer 2 Report

Comments and Suggestions for Authors

General comments: This is a narrative review of different cardiac imaging modalities and how they can improve guidance of VT ablation for improved cardiac and patient outcomes. It is relevant as VT has high morbidity and mortality if untreated. Ablation has risk factors thus improving targeted treatment with reduced adverse effects is important. The review is comprehensive in describes the different imaging modalities. Additional of more visual images of each modality would help clarify differences for the reader, as well as adding the limitations to Figure 1 or in the separate figures. The review is quite lengthy and some areas are too technical, so this should be shortened and simplified for reader clarity. The search/review methodology is missing and needs to be described. Also, grammatical errors with incomplete sentences and one section written in Italian should be corrected. The descriptive nature of the review should be made more critical with supporting references justifying each imaging modality and in which situations each one should be considered/used. The authors can also add cost-effectiveness data.

Title: The title describes the study but the authors can add that this is a narrative review.

Abstract: is succinct and gives an overview of the main study points. It mentions the importance of cardiac imaging to guide invasive therapy and assess the success of VT ablation.

Introduction – Section 1: Begins by emphasizing the negative effects of untreated VT on the heart and patient quality of life. The authors describe the role of catheter VT ablation and support it with studies from the literature. Electroanatomic mapping alone is limited to the surface, and cardiac imaging bridges this gap by viewing the entire 3D structure of the heart to guide intervention. They describe the types of cardiac imaging used.

-The language is clear in this section but it reads like an educational textbook. What is the novelty of this review that is changing patient care and distinguishes this review from other current studies?

Section 2 and Tables 1&2 are nicely organized into pre/intra/post-procedural and which anatomical/functional/tissue information each modality provides for direct comparison between imaging modalities.

Section 2.1 has incomplete sentences that need corrected (e.g. with an incidence that can exceed… and with long-term mortality rates of 10-20…)

-Certain sections of the paper read very technically and are hard to understand. For example, Section 2.2 paragraphs 5-6. I would suggest shortening this or moving some of the technical language to the supplement so that readers can better understand the main highlights of the imaging modalities and stay focused on this while reading through the paper.

-Lines 218-223 are in Italian and need to be translated to English.

-Line 267 define LAVA here. Removed parentheses from line 352.

-Line 439 the sentence is incomplete

Section 4.1 and 4.2 describe limitations of current studies and imaging modalities. Adding a table with the limitations for each (or adding these to Figure 1) would help the readers better understand the differences.

Methods: This section is missing. The authors should include methodology on how they performed the review. Is this a narrative review? How did they obtain their sources and with what inclusion/exclusion criteria? Did they do a comprehensive search? Using what databases? Did one or two people perform the search, on what date, were there any limits set, etc? How did they factor study bias or strength? Add whether the PRISMA guidelines were followed and add the completed checklist as a supplemental file. Also add IRB approval or exemption information.

Conclusions: Summarizes the main study points. Also describes possible future directions with AI and automation.

Figures: Figure 1 nicely summarizes the pros of each cardiac imaging modality and how it can help guide VT ablation strategies. The color coding and boxes are clear. The authors can add a limitations section at the bottom of each box for each imaging modality.

-Would suggest adding images of echocardiography, speckle-tracking, cardiac MRI, etc so that the readers can visualize what the different imaging modalities look like and how the cardiac images being produced appear.

References: The references are comprehensive and updated, citing guidelines from the European Society of Cardiology, LAHRS expert consensus statement, and other studies from the literature.

Author Response

Reviewer 2 Comment 1 Additional of more visual images of each modality would help clarify differences for the reader, as well as adding the limitations to Figure 1 or in the separate figures.

ANSWER:Some figures were not included because they were difficult to obtain or are still awaiting permission for free use.

 

 

Reviewer 2 Comment 2 The review is quite lengthy and some areas are too technical, so this should be shortened and simplified for reader clarity.

ANSWER:Some parts have been removed to provide greater clarity.

 

 

Reviewer 2 Comment 3

 The search/review methodology is missing and needs to be described.

ANSWER: In the conclusions, the research methodology has been briefly summarized and included.

 

Reviewer 2 Comment 4

ANSWER:The part in Italian has been corrected and was included by mistake because it had been commented out, due to a typing error. Grammatical errors have been corrected.

 

 

Reviewer 2 Comment 4

 The descriptive nature of the review should be made more critical with supporting references justifying each imaging modality and in which situations each one should be considered/used.

ANSWER: we add a section in ‘Multimodality Imaging in the context of Ventricular Tachycardia Ablation’ paragraph

 

Reviewer 2 Comment 5 Add a Cost-effectiveness data

ANSWER:The section “Cost-effectiveness data” has been added.

 

 

 

 

Reviewer 2 Comment 6

Title: The title describes the study but the authors can add that this is a narrative review.

ANSWER:Title has been modified.

 

 

Reviewer 2 Comment 7

Abstract: is succinct and gives an overview of the main study points. It mentions the importance of cardiac imaging to guide invasive therapy and assess the success of VT ablation.

Introduction – Section 1: Begins by emphasizing the negative effects of untreated VT on the heart and patient quality of life. The authors describe the role of catheter VT ablation and support it with studies from the literature. Electroanatomic mapping alone is limited to the surface, and cardiac imaging bridges this gap by viewing the entire 3D structure of the heart to guide intervention. They describe the types of cardiac imaging used.

-The language is clear in this section but it reads like an educational textbook. What is the novelty of this review that is changing patient care and distinguishes this review from other current studies?

ANSWER: The review combines the most recent clinical evidence, including multicenter registries published between 2023 and 2025, together with procedural and clinical data, to assess the real impact of imaging in the management of ventricular tachycardia. It provides practical guidance on how to choose the most appropriate imaging modality (CMR, CT, PET, or ICE) and suggests criteria to identify patients who are more likely to benefit from imaging integration.It also highlights the main gaps in current knowledge and proposes clear directions for future research, such as randomized trials, standardized protocols, cost-effectiveness studies, and validation of artificial intelligence algorithms. In summary, this is not just a descriptive or educational text, but a critical synthesis aimed at translating current evidence into practical recommendations and focused research strategies.

 

Reviewer 2 Comment 8

 

Section 2 and Tables 1&2 are nicely organized into pre/intra/post-procedural and which anatomical/functional/tissue information each modality provides for direct comparison between imaging modalities.

Section 2.1 has incomplete sentences that need corrected (e.g. with an incidence that can exceed… and with long-term mortality rates of 10-20…)

ANSWER:Corrected: due to a typing error, the \ before % was missing.

 

 

Reviewer 2 Comment 9

-Certain sections of the paper read very technically and are hard to understand. For example, Section 2.2 paragraphs 5-6. I would suggest shortening this or moving some of the technical language to the supplement so that readers can better understand the main highlights of the imaging modalities and stay focused on this while reading through the paper.

ANSWER:the section has been simplified

 

 

Reviewer 2 Comment 10

-Lines 218-223 are in Italian and need to be translated to English.

ANSWER: The Italian sentences have been translated. Grammatical errors have been corrected.

 

 

Reviewer 2 Comment 11

-Line 267 define LAVA here. Removed parentheses from line 352.

ANSWER:  Done. Some bibliographic references were also corrected.

 

 

Reviewer 2 Comment 12

-Line 439 the sentence is incomplete

ANSWER:Corrected: due to a typing error, the \ before % was missing.

 

 

 

Reviewer 2 Comment 13

Section 4.1 and 4.2 describe limitations of current studies and imaging modalities. Adding a table with the limitations for each (or adding these to Figure 1) would help the readers better understand the differences.

ANSWER: We add the limitations section to FIGURE 1.

 

 

Reviewer 2 Comment 14

Methods: This section is missing. The authors should include methodology on how they performed the review. Is this a narrative review? How did they obtain their sources and with what inclusion/exclusion criteria? Did they do a comprehensive search? Using what databases? Did one or two people perform the search, on what date, were there any limits set, etc? How did they factor study bias or strength? Add whether the PRISMA guidelines were followed and add the completed checklist as a supplemental file. Also add IRB approval or exemption information.

 

ANSWER: We add the methods section. This study is a review of published literature and did not involve new data collection from human participants or animals; therefore, Institutional Review Board approval and informed consent were not applicable.

 

 

Reviewer 2 Comment 15

 

Conclusions: Summarizes the main study points. Also describes possible future directions with AI and automation.

Figures: Figure 1 nicely summarizes the pros of each cardiac imaging modality and how it can help guide VT ablation strategies. The color coding and boxes are clear. The authors can add a limitations section at the bottom of each box for each imaging modality.

 

ANSWER: We add the limitations section.

“We also provided a novel caption for Figure 1. Multimodality imaging support for ventricular tachycardia (VT) ablation.
 The left panel illustrates a typical VT ablation workflow, including fluoroscopy, ECG/EGM monitoring and electroanatomical mapping (EAM). The right panel summarizes the complementary roles of major imaging modalities—intracardiac echocardiography (ICE), cardiac magnetic resonance (CMR), cardiac computed tomography (CCT), and nuclear imaging (PET/SPECT)—in supporting substrate characterization, procedural planning, target identification and intraprocedural safety. For each modality, the principal clinical contributions and the main methodological or practical limitations are summarized.

 

 

 

Reviewer 2 Comment 16

-Would suggest adding images of echocardiography, speckle-tracking, cardiac MRI, etc so that the readers can visualize what the different imaging modalities look like and how the cardiac images being produced appear.

ANSWER: Such images tare hard to obtain and, if they do exist, require authorization to be used.

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer’s comments:

The manuscript is comprehensive and clinically relevant. The main improvements needed are careful editing, clearer structure in certain sections, stronger discussion of limitations, and refinement of figures and tables. Addressing these points will significantly enhance the scientific quality and readability of the paper.

 

Major Comments:

 

1. The manuscript needs careful proofreading because several sentences are incomplete and some numbers are missing. In a few places, percentages and survival rates are cut off or unfinished. This makes the paper look unpolished and may reduce confidence in the data presented. Please review the entire manuscript and ensure all statistics, percentages, and ranges are complete and correctly written.

 

2. Some language and formatting issues need correction. A few words are misspelled, and one paragraph contains text in Italian instead of English. There are also some small formatting inconsistencies in the abbreviation section. The manuscript would benefit from professional English editing to improve clarity and eliminate these minor but important errors.

 

3. The paper would be stronger if you briefly explained how the literature was selected. Even in a narrative review, readers should understand how studies were selected. A short paragraph describing which databases were searched, the time period covered, and the types of studies prioritized would improve transparency and credibility.

 

4. You introduce the difference between “imaging-aided” and “imaging-guided” procedures, but the distinction could be explained more clearly. The concept is important, yet it is described in slightly different ways in different sections. It would help to define both terms clearly in one place, possibly with a small comparison table or figure.

 

5. The tables are informative but could be improved. Some words are broken across lines, some terms are inconsistent, and some metrics lack units. Please revise the tables to ensure consistent terminology and formatting. Making the tables cleaner will improve readability.

 

6. While you mention that most evidence comes from observational studies, the critical discussion of study limitations could be stronger. It would help to clearly state that many studies may be influenced by center expertise, patient selection, and imaging quality. A short paragraph explicitly discussing these limitations would make the review more balanced and scientifically rigorous.

 

7. Figure 1 provides a useful overview, but it could be more detailed. Currently, it is somewhat schematic. You may consider adding arrows to show workflow progression or clarifying how imaging data are integrated into mapping systems. Improving the figure would enhance its educational value.

 

8. The conclusion mostly repeats earlier points. It would be stronger if it clearly summarized what is well established, what remains uncertain, and what future research should focus on. A more forward-looking conclusion would leave a stronger final impression.

 

9. In some sections, the wording sounds slightly too confident about the benefits of imaging integration. Since most evidence is observational and randomized trials are still ongoing, the tone should remain cautious. Adjusting some statements to reflect this uncertainty would make the manuscript more balanced.

 

10. The abbreviation section should be cleaned up. Some entries contain extra explanations or inconsistent formatting. Please standardize the format and ensure that every abbreviation listed is used in the text and defined when first introduced.

 

 

General but important suggestions:

• Avoid citing preprints unless they are essential and make a significant contribution to the topic.
• Ensure that no retracted papers are cited.
• Verify that all equations, units, and symbols are written according to standard scientific conventions.
• Maintain consistency in spelling and terminology throughout the manuscript (e.g., use either tumor or tumour, but not both).
• Check the numbering of all headings, figures, and tables to ensure correct sequence.
• Review the captions of tables and figures, as well as section headings, to correct any errors and ensure clarity.
• Make sure that all figure/table captions are self-explanatory and informative.
• Figures and tables must be referred to in the main text, and a brief explanation must be provided. I mean, cite each figure/table at the appropriate location in the text.
• Use a reference management tool such as EndNote to cite other papers in your manuscript.
• Citations in number format, such as [], shall only come at the mid or end of the text.
• Eliminate duplicate text and avoid repeating the same theme or idea multiple times.
• Ensure that the text flows logically, with clear connections between paragraphs and sections.
• Please give the source of the data or cite the source if the data is public.
• In theoretical sections like introduction and literature review, if you are quoting any statement from previously published sources, then you must give their citation (references).
• Add the equation in an editable format using a tool like MathType, then make sure there are no mistakes.
• Ensure the spellings of the labels in the figures are correct and legible.
• In the introduction/literature review sections, only add the studies that are relevant to your research.
• The title and abstract should explicitly state the exact task addressed in the paper (e.g., classification, segmentation, or detection, etc.), as this is essential for clearly conveying the scope and objective of the work to the reader.
• Sometimes authors use AI tool for improving English language but mistakenly copy and paste ChatGPT/AI tools leftover conversations into the paper. So read each section and remove such conversations if exists.

Author Response

Reviewer 3 Comment 1

1. The manuscript needs careful proofreading because several sentences are incomplete and some numbers are missing. In a few places, percentages and survival rates are cut off or unfinished. This makes the paper look unpolished and may reduce confidence in the data presented. Please review the entire manuscript and ensure all statistics, percentages, and ranges are complete and correctly written.

ANSWER:The entire manuscript has been thoroughly revised. Many of the errors or omissions were due to typographical mistakes and the presence of misplaced backslashes or inadvertently commented sections. All issues have now been corrected.

 Reviewer 3 Comment 2

1. Some language and formatting issues need correction. A few words are misspelled, and one paragraph contains text in Italian instead of English. There are also some small formatting inconsistencies in the abbreviation section. The manuscript would benefit from professional English editing to improve clarity and eliminate these minor but important errors.

ANSWER:A thorough revision has been carried out, and many errors have been corrected.

 

 Reviewer 3 Comment 3

1. The paper would be stronger if you briefly explained how the literature was selected. Even in a narrative review, readers should understand how studies were selected. A short paragraph describing which databases were searched, the time period covered, and the types of studies prioritized would improve transparency and credibility.

ANSWER:A section has been added to the manuscript specifying the sources of the selected articles and the time period covered.

 

 Reviewer 3 Comment 4

1. You introduce the difference between “imaging-aided” and “imaging-guided” procedures, but the distinction could be explained more clearly. The concept is important, yet it is described in slightly different ways in different sections. It would help to define both terms clearly in one place, possibly with a small comparison table or figure.

ANSWER: The requested changes have been made to the table and the figure.

 

 Reviewer 3 Comment 5

1. The tables are informative but could be improved. Some words are broken across lines, some terms are inconsistent, and some metrics lack units. Please revise the tables to ensure consistent terminology and formatting. Making the tables cleaner will improve readability.

ANSWER: we revised the tables

 

 Reviewer 3 Comment 6

1. While you mention that most evidence comes from observational studies, the critical discussion of study limitations could be stronger. It would help to clearly state that many studies may be influenced by center expertise, patient selection, and imaging quality. A short paragraph explicitly discussing these limitations would make the review more balanced and scientifically rigorous.

ANSWER:A section has been added to the manuscript at the end of the 4.2 section.

 

 Reviewer 3 Comment 7

1. Figure 1 provides a useful overview, but it could be more detailed. Currently, it is somewhat schematic. You may consider adding arrows to show workflow progression or clarifying how imaging data are integrated into mapping systems. Improving the figure would enhance its educational value.

ANSWER: The requested changes have been made to the table and the figure.

 

 Reviewer 3 Comment 8

1. The conclusion mostly repeats earlier points. It would be stronger if it clearly summarized what is well established, what remains uncertain, and what future research should focus on. A more forward-looking conclusion would leave a stronger final impression.

ANSWER: corrected

Reviewer 3 Comment 9

1. In some sections, the wording sounds slightly too confident about the benefits of imaging integration. Since most evidence is observational and randomized trials are still ongoing, the tone should remain cautious. Adjusting some statements to reflect this uncertainty would make the manuscript more balanced.

 Reviewer 3 Comment 10

1. The abbreviation section should be cleaned up. Some entries contain extra explanations or inconsistent formatting. Please standardize the format and ensure that every abbreviation listed is used in the text and defined when first introduced.

ANSWER: abbreviation has been corrected

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors improved the manuscript by shortening the length and removing highly technical language for improved reader clarity. They improved Figure 1 as an illustrative summary of the different imaging modalities that can be used in VT ablation and added limitations to each modality. The authors added pertinent search and methodology details to the methods section. They added the PRISMA guidelines and a paper flow diagram as Figure 2. They added pertinent clinical details about deciding between the cardiac imaging modalities. The future directions and limitations section nicely expands on the narrative review findings for potential future studies, including that this data is all observational.

Author Response

We want to thank the reviewer for the appreciation of our work.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript is scientifically sound, relevant, and suitable for publication once the minor editorial issues are corrected.

Remaining Minor Issues:

Some citation formatting could be standardized (e.g., [92–94] instead of [92] [93] [94]). IF journal allows your current format then ignore this comment.
2. A short duplicated paragraph appears in the limitations section.
3. Minor table formatting consistency could be further refined.

Author Response

Comments 1: Some citation formatting could be standardized (e.g., [92–94] instead of [92] [93] [94]). IF journal allows your current format then ignore this comment.

We fixed this format.

Comment 2. A short duplicated paragraph appears in the limitations section.

We deleted the paragraph

Comment 3. Minor table formatting consistency could be further refined.

We fixed this proble.