Ventricular tachycardia (VT) is one of the major causes of sudden cardiac death (SCD). In general, VT could be managed with antiarrhythmic drugs (AADs) therapy, catheter ablation and implantable cardioverter defibrillators (ICD). While the AADs therapy and catheter ablation have been shown to reduce the recurrence of VT, only the ICD therapy is effective in aborting SCD. The recently published VANISH trial reveals that VT catheter ablation significantly decreases the rate of death, VT storm and appropriate ICD shock comparing with an escalation of AADs therapy for ischemic cardiomyopathy (ICM). However, the mapping strategies and feasibility of VT catheter ablation are often limited by the hemodynamically intolerant VT. Substrate modification strategy and percutaneous left ventricular assist device (pLVAD) are often used to overcome the hemodynamic intolerance. So far there are no large-scale randomized clinical trials comparing different mapping strategies in the setting of hemodynamically unstable VT, specifically when it comes to risk stratification for patients with hemodynamic instability. The aim of the present article is to systemically review different VT mapping strategies, the role of pLVAD in hemodynamically intolerant VT ablation with a special consideration of high risk VT.