Rupture of a Large Aortic Pseudoaneurysm into the Right Ventricle with Formation of Aorto-right Ventricular Fistula

Aortic pseudoaneurysms pose a higher risk of rupture due to elevated wall shear stress. Rupture into cardiac chambers is exceedingly rare, with no prior reported cases of an aortic pseudoaneurysm rupturing into the right ventricle. A 57-year-old man with a history of prior surgical ventricular septal defect repair, hypertension, and polysubstance use presented after being found unconscious and reported chest pain. Initial imaging revealed a large ascending aortic pseudoaneurysm (6.6 × 6.1 × 5.5 cm). While under conservative management with antihypertensive therapy, the patient developed cardiogenic shock and was found to have a new aorto-right ventricular fistula on echocardiography. Emergent surgical repair was conducted with patch repair of the fistula, ascending aorta replacement with a 34 mm graft, and placement of a right ventricular assist device for right ventricular failure. Prior cardiac surgery and poorly controlled hypertension likely contributed to pseudoaneurysm formation and subsequent rupture. The development of an aorto-right ventricular fistula introduced significant hemodynamic instability, necessitating high-risk surgical intervention. Multidisciplinary care is crucial for such rare and challenging presentations.