a 48-year - old female presented to the emergency department ( ed ) with syncope . her past medical history was significant for mild mental retardation , former tobacco use , and hernia repair . the patient stated that while cooking she felt lightheaded , subsequently lost consciousness , and fell to the ground recovering after a few minutes . after recovering , she noticed her exercise tolerance declined , feeling shortness of breath after climbing just one flight of stairs . on review of systems , she reported 2 weeks of menorrhagia . she denied chest pain , palpitations , diaphoresis , lower extremity edema , orthopnea , and paroxysmal nocturnal dyspnea . on physical examination , her heart rate was 88 beats / min , blood pressure 113/48 mmhg , oxygen saturation 98% on room air , and a temperature of 98.4c . cardiac examination revealed a 3/6 decrescendo diastolic murmur best heard on the right sternal border with radiation to the carotids . the physical exam was also remarkable for poor dentition with evidence of decay in multiple teeth as well as pallor in mucous membranes , palms , and soles . laboratory workup was remarkable for profound iron deficiency anemia ( hgb 2.9 g / dl , hct . 10.7% , mean corpuscular volume 54 fl , ferritin 15 ng / ml , iron 261 g / dl , transferrin 218 mg / dl ) her chest x - ray ( cxr ) showed cardiomegaly , computed tomography ( ct ) of the head ruled out hemorrhage , and ct of the abdomen / pelvis revealed multiple myomas which were thought to be the source of bleeding . due to a new diastolic murmur and cardiomegaly on cxr , a transthoracic echocardiogram ( tte ) was obtained , demonstrating a thickened aortic valve with severe aortic insufficiency . given high suspicion for ie , a transesophageal echocardiogram ( tee ) was performed revealing an irregularly shaped mobile echodensity ( 1.7 cm1.0 cm ) on the aortic valve consistent with a vegetation ( fig . 1 ) . also , a root abscess was present with fistula formation between the right sinus of valsalva and the right atrium ( fig . broad - spectrum antibiotics were started with vancomycin and ceftriaxone , and she was transferred to the cardiac care unit . blood cultures were positive for streptococcus anginosus and antibiotics were narrowed to ceftriaxone for 4 weeks . cardiac surgery service was consulted for aortic valve repair ( avr ) and repair of the fistula . tee at the mid - esophageal level showing vegetation ( * ) on the aortic valve and fistula formation ( arrow ) between the aortic root and the right atrium . the next day the patient underwent avr with a bioprosthetic valve and bovine patch repair of sinus of valsalva fistula . she remained hemodynamically stable , but required permanent pacemaker implantation due to permanent complete atrioventricular block post - surgery . at a month follow - up , the patient has been stable , with normal valvular function , and preserved ejection fraction . acf is a rare entity occurring in less than 2.2% of native valve endocarditis ( 1 ) . the most common agents are staphylococcus aureus , streptococcus spp . , enterococcus spp . , and other less common bacterial and fungal infections ( 1 , 2 ) . it is thought that the process leading to an acf is the resulting inflammation from the bacterial colonization of the valve and surrounding tissue with subsequent abscess formation , creating erosion of the sinus of valsalva ( 13 ) . the intervalvular fibrosa is particularly prone to infection given its avascularity and infected regurgitation of jet striking subvalvular structures ( 4 ) . a left - to - right shunt is created from any of the aortic valve sinuses into any of the cardiac chambers without preference , which causes hemodynamic instability ( 2 , 5 ) . therefore , clinical presentation can range from a non - clinically significant murmur , to a chest pain syndrome , acute coronary syndrome , refractory heart failure , or even aortic dissection ( 6 , 7 ) . reported cases of aortocavitary fistula sob , shortness of breath ; acs , acute coronary syndrome ; tavr , transcatheter aortic valve replacement ; hocm , hypertrophic obstructive cardiomyopathy . as seen in our index case , acf has been documented most commonly in cases of aortic valve ie , more in prosthetic than native aortic valves ( 5 , 8) . acf rarely presents as a complication of right - sided ie , and when that is the case , it is usually a late presentation ( 9 , 10 ) . clinical scenarios from primary ie as in our case have also been described with cardiac surgery ( 11 , 12 ) , percutaneous interventions ( 13 ) , chest trauma , and autoimmune process ( 14 ) . though clinical presentation of acf will be determined mainly by the inciting primary process and the size of the shunt , the variety of the initial clinical presentations can range from acute decompensated heart failure ( 6 ) to asymptomatic patients with only an associated murmur ( 15 , 16 ) . when symptomatology is poor , a high index of suspicion is required , especially in the background of recent surgery or ie . the acf murmur has been described as a continuous - thrill murmur ( 17 , 18 ) . the median time for the echocardiographic diagnosis of the fistula is usually 1 month after onset of symptoms ( 5 ) . tte is usually the first imaging method used , although tee is a better modality to describe valvular and paravalvular pathology ( 19 , 20 ) , with better delineation of function and morphology ( 19 , 20 ) . in both , tte and tee , color doppler can detect a highly turbulent flow between the aorta and the cardiac chambers ( 5 ) . recently , three - dimensional echocardiography has also emerged as an excellent modality to delineate anatomic and unconventional views of cardiac structures detecting volume data , cropping , and slicing in various planes ( 2123 ) . ct can be considered as a useful complement in visualizing the cardiac lesions of ie if echocardiography is inconclusive . it provides assessment of valvular and perivalvular involvement , extra - cardiac lesions , and non - invasive evaluation of the coronary artery anatomy , simultaneously ( 24 ) . moreover , comprehensive evaluation of anatomic relationships of perivalvular abscess / pseudoaneurysms may be beneficial for presurgical planning ( 25 ) . this can also be accomplished with cardiac magnetic resonance and aortography ; both of which can provide an excellent anatomical and flow dynamic description of the acf before closure ( 2629 ) . disadvantages of ct and angiography compared to echocardiography are the contrast - induced nephropathy and radiation exposure . acf carries severe morbidity and mortality , especially in patients who are elderly , have severe heart or renal failure , require emergent procedures , or are infected with staphylococcus ( 1 , 3 , 5 ) . acute and subacute ie can present in different forms with subtle clinical signs and symptoms . physical examination and non - invasive imaging are essential in the diagnosis and management of ie . paravalvular complications of ie should be treated in a timely manner to avoid further destruction of paravalvular tissue including the conduction system . the authors have not received any funding or benefits from industry or elsewhere to conduct this study .