Apreviously fit and well 34 year old man was admitted with a six week history of increasing breathlessness and non-productive cough. He was febrile with splinter haemorrhages present and in cardiac failure. He had a wide pulse pressure and a long early diastolic murmur. The PR interval was prolonged at 300 ms. A transthoracic echocardiogram confirmed severe aortic regurgitation secondary to an infected bicuspid aortic valve. Transoesophageal echocardiography (TOE) revealed a highly disorganised bicuspid aortic valve with mobile vegetations attached to both cusps and an aortic root abscess. Blood cultures subsequently grew Streptococcus viridans. The patient underwent an emergency aortic valve replacement with a Starr Edwards prosthesis since no homograft was available. The intraoperative findings were of an extensive pancarditis with a fibrinous pericardial effusion. The aortic valve was virtually destroyed by infection and the aortic abscess bulged into the right atrium, where the atrial wall was described as “paper thin”. The patient started to make a good recovery early in the postoperative period but a week later he developed acute right heart failure. A repeat TOE (right) revealed a fistula from the original abscess cavity into the right atrium (AVR, aortic valve replacement). Despite aggressive diuretic treatment, he continued with symptomatic right ventricular failure secondary to overload. After completing a course of penicillin and gentamicin, the patient did not appear to be infected and an aortic to right atrium fistula repair was undertaken using a bovine pericardial patch. The patient made a good recovery from his surgery.

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