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An aortic pseudoaneurysm is formed when injury through all three layers of the aortic wall allows leakage through it and formation of haematoma contained within a weakened wall outside the aorta. It differs from a true aneurysm which refers to dilatation of all 3 layers of the wall and from a dissection as this describes a defect in the intimal layer that propagates a separation of it from the medial layer. Causes of pseudoaneurysm in the ascending aorta include cardiac surgery and trauma with pre-existing aortic disease and peri-operative infection giving a predisposition to this complication. Complications from aortic pseudoaneurysm include bleeding, rupture and symptoms pertaining to mass effect. We describe a case of a fistulous communication with associated shunting as a rare complication of iatrogenic aortic pseudoaneurysm, manifesting as clinical heart failure.

A 73-year-old man presented to the Emergency Department with a three-week history of chest pain and worsening dyspnoea. Physical examination revealed signs of right-sided heart failure. His past medical history included a mechanical aortic valve replacement for bicuspid aortic stenosis and subsequent implantation of an ascending aortic graft for an aneurysmal ascending aorta. At this presentation, computed tomography showed a giant, dissected pseudo-aneurysm (arrow) arising from the aorta above the origin of the coronary arteries with near-complete effacement of the superior vena cava (SVC) and pulmonary artery (PA). There was fistulous communication between the aorta and PA (circle). Subsequent echocardiography showed fenestrated ulcerative communications between the pseudo-aneurysm and the main PA (video). A dissected pseudo-aneurysm not only has mechanical implications but can rarely present with an ulcerative fistula and associated shunt. The patient refused operative management and passed away less than 24 hours after presentation.