CMR unravels a complex left ventricular pseudo-aneurysm as the cause of ventricular tachycardia in a patient with retroviral disease an syphilis (QF_FR_090)

Description of Clinical Presentation: A 32 years old mother of 4 presented to a local hospital with heart failure. She shortly thereafter developed refractory ventricular tachycardia (and cardiogenic shock) requiring multiple DC cardioversion and anti-arrhythmic drugs over 24 hours before maintaining sinus rhythm. She required ionotropic support for a few days. She had a history of HIV since 2014 but was poorly compliant with ARV treatment. Her viral load was 103copies/mL, with CD4 count of 550 cells/µL. Troponin levels were not raised and her coronaries were normal. Her NTproBNP was 10050ng/L. Her RPR and TPHA were positive and she was put on appropriate therapy. As her D-dimer was 6.1mg/L, a CTPA was performed, which was negative for pulmonary embolism, but revealed enlarged mediastinal lymphnodes - which were thought to be tuberculous and TB treatment was initiated. Echocardiography showed a left ventricular ejection fraction of 32% and a suggestion of a left ventricular aneurysm, but inconclusive. This necessitated a Cardiac MRI, which was conclusive and the patient was submitted for surgical resection of a large LV apical pseudo aneurysm and a patch repair. She was subsequently discharged on heart failure therapy as well as therapies for her other comorbidities.

Diagnostic Techniques and Their Most Important Findings: Pre operative CMR showed a large complex pseudo aneurysm extending from the LV apex and filled with thrombus (Fig 1 and 2).
Post operative VLA cine CMR imaging after successful resection of the pseudo aneurysm and an apical patch (Fig 3)

Learning Points from this Case: Most left ventricular aneurysms and pseudo aneurysms occur as a complication of myocardial infarction. Although advanced untreated HIV can cause dilated cardiomyopathy and heart failure, LV aneurysms or pseudo aneurysms have hardly been described in relation thereto. A case series of LV aneurysm attributable to syphilis was described from South Africa, but this was long before the era of echocardiography and novel imaging using CMR. We describe a case of a young mother who presented with malignant arrhythmias due to a large complex LV pseudo aneurysm that could only be clearly defined by CMR. She had normal coronaries and the most likely cause for her myocardial damage is HIV.