An 88-year-old woman with a prior history of aortic stenosis and history of valvuloplasty presented with worsening symptoms of heart failure and dizziness. She underwent successful transcatheter aortic valve replacement (TAVR) without complications. Follow-up echocardiograms revealed a small fistula connecting aorta to the right ventricle. The patient was initially asymptomatic but 3 months later developed overload of the right ventricle and heart failure and chose to continue medical therapy. She died of progressive heart failure at 9 months from onset of fistula. Aorto-right ventricular fistula is a rare complication of TAVR with only four cases reported in literature thus far.

Left ventricular pseudoaneurysm (LVPA) is associated with a significant mortality rate of up to 45% in the first year after diagnosis. It is a very rare entity and hence the true incidence and natural history are not clearly known. Clinical presentation varies widely and requires a high index of suspicion for diagnosis. We report the case of a 72-year-old woman with a remote history of left ventricular aneurysm repair during coronary bypass surgery who presented to the emergency department with acute onset of left-sided chest pain and a pulsatile chest wall swelling. She was haemodynamically stable but required an intravenous morphine drip for pain control. Contrast-enhanced computed tomography of the chest showed a large LVPA dissecting through the anterior chest wall. Surgical treatment was discussed with the patient but she opted in favour of comfort care. She died 5 days later from complete rupture of the LVPA. With this report, we aim to raise the level of awareness of LVPA that could anatomically expand and rupture. Early diagnosis and timely surgical intervention is the treatment of choice. LEARNING POINTS• It is important to recognize left ventricular pseudoaneurysm as a rare cause of sudden onset chest pain in a patient with history of myocardial infarction with/without coronary artery bypass grafting and presenting with a pulsatile chest wall mass on physical examination.• Echocardiography is usually used for diagnosis, which is confirmed by CT or MRI of chest, while open surgical or percutaneous closure are the available treatment options.• Mortality rates are very high even with surgical treatment in these complex patients. KEYWORDSLeft ventricular pseudoaneurysm; acute chest pain; surgical repair of left ventricular aneurysm; computerized tomography in diagnosis of left ventricular aneurysm CASE DESCRIPTION A 72-year-old Caucasian woman with a history of hypertension, myocardial infarction and ischaemic cardiomyopathy underwent coronary artery bypass surgery (CABG). During CABG, she received the left internal mammary artery to the left anterior descending artery, a saphenous vein graft (SVG) to the obtuse marginal and another SVG to the right postero-lateral branch. She also had repair of a small left

A 75-year-old woman was admitted into the intensive care unit, with severe sepsis and renal failure. She developed purpura fulminans (PF) of bilateral upper and lower extremities along with gangrene on the tips of her fingers and toes. Blood cultures confirmed Pasteurella multocida as the causative organism. Despite aggressive supportive measures, the patient remained dependent on high doses of vasopressors and the gangrene progressed. She ultimately succumbed to her underlying severe sepsis. PF is a rare and fatal dermatological emergency commonly seen in children, but it also occurs in adults. Acute infectious PF occurs secondary to severe sepsis and P. multocida is a rare cause of PF. To the best of our knowledge, this is only the second reported case of PF due to P. multocida in an adult.