Aortic Pseudoaneurysm with Fistulization into the Pulmonary Artery: A Cause of Refractory Heart Failure After Bentall Procedure

We present the case of a patient who developed left-sided congestive heart failure several years after undergoing composite graft surgery for annuloaortic ectasia and aortic regurgitation. Transthoracic echocardiography showed markedly elevated left ventricular filling pressures and severe pulmonary hypertension. However, no underlying pathology or anatomic abnormality to explain the high filling pressures could be identified. On transesophageal echocardiography, a large aortic pseudoaneurysm was demonstrated arising from dehiscence of the distal graft anastomosis to the native aorta. A fistulous communication was noted between the pseudoaneurysm and the right pulmonary artery resulting in a large aortopulmonary shunt. This case illustrates the inherent limitations of transthoracic echocardiography in the detection of complications after composite graft surgery of the aorta.