Large aortic pseudoaneurysm, from left coronary ostium, with aortopulmonary fistula 10 years after aortic root replacement for type a aortic dissection.

A 66-year-old man presented with anorexia, unexplained weight loss, worsening shortness of breath, and atrial fibrillation. Ten years before this presentation, he had undergone urgent aortic root replacement to treat an acute type A aortic dissection at a different center. Clinical examination revealed a systolic murmur (grade 3/6) and an early diastolic murmur. An initial chest radiograph did not show evidence of cardiac failure. With continued deterioration of his clinical state, a subsequent chest radiograph performed 7 months later showed cardiomegaly, pulmonary congestion, and a left pleural effusion. A diagnosis of congestive heart failure was made. Figures 1 and 2 show his chest radiographs first at initial presentation (Figure 1) and then 7 months later (Figure 2). The atrial fibrillation progressed from paroxysmal to persistent, with attempted cardioversions failing to restore sinus rhythm. During this time, he experienced weight loss of 19 kg over a period of 8 weeks. A computed tomographic scan of his abdomen was performed to investigate a possible intraabdominal tumor. It showed no evidence of intra-abdominal neoplasia. However, it revealed a nodule in the lower lobe of his left lung. A computed tomographic scan of his chest showed the left lung nodule to be a 3-cm rounded, soft lesion of soft tissue density (Figure 3) with no lymphadenopathy. It also revealed a very large collection around the aortic root and ascending aorta. An additional contrast-enhanced computed tomographic scan of the chest revealed this collection to be a large false aneurysm measuring 9.5 by 14 cm around the aortic root, with a large communication between the aortic root and the aneurysm and also a communication between the pseudoaneurysm and the pulmonary artery (Figures 4 and 5). A 3-dimensional reconstruction of the computed tomographic images shows the relationship of the pseudoaneurysm to surrounding structures (Movie I in the online-only Data Supplement). Transesophageal echocardiography and left heart catheterization showed an abnormal connection with continuous flow from the left main coronary artery into the chamber of the aneurysm (Movie II in the online-only Data Supplement). Percutaneous closure of the ostium of the pseudoaneurysm was considered, but not attempted, because it was doubtful Figure 1. First chest radiograph taken after presentation. Figure 2. Chest radiograph taken just before diagnosis with computed tomography.