Imagenomics and Ventricular Arrhythmia: The Scar, The Channel, The Variant.

Background: Imagenomics is an emerging clinical framework that combines advanced imaging and genetic profiling to refine risk stratification and advance precision medicine in the management of ventricular arrhythmias.

Case Summary: A 43-year-old woman presented with palpitations and presyncope. Ambulatory electrocardiogram revealed frequent premature ventricular contractions and nonsustained ventricular tachycardia, consistently initiated by a premature ventricular contraction with distinct morphology. Cardiac magnetic resonance scan identified a nonischemic scar in the basal inferolateral segment of the left ventricle, with a protected conduction corridor of heterogeneous tissue within the border zone. Electroanatomic mapping confirmed a critical isthmus that was anatomically colocalized with the cardiac magnetic resonance-defined corridor. Programmed ventricular stimulation induced sustained monomorphic ventricular tachycardia that degenerated into ventricular fibrillation, necessitating implantable cardioverter-defibrillator placement. Genetic analysis revealed a heterozygous, likely pathogenic TECRL variant, associated with catecholaminergic polymorphic ventricular tachycardia type 3.

Discussion: This case highlights a composite arrhythmogenic mechanism shaped by myocardial scar substrate, protected conduction architecture, and inherited susceptibility.