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An 81 year old man with known severe aortic stenosis and atrial fibrillation, in the presence of very poor ventricular function, was admitted to hospital complaining of severe chest pain. The pain was sharp, associated with nausea, and radiated to his back. Computed tomography (CT) of his thorax excluded thoracic aortic dissection but did show a right atrial mass and possible left atrial thrombus. Transoesophageal echocardiography showed a right atrial venous cast and a left atrial thrombus. A venous cast represents thrombus that has formed in a deep vein assuming its shape. The hollow cast has become dislodged from the deep vein and become trapped within the right atrium—presumably becoming enmeshed within vestigial inferior vena cava valve structures or the Chiari network. While both pathologies are seen in echocardiographic practice it is unusual for them to occur together in an anticoagulated patient.