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The patient is a 46 year old man with hypertension who on routine physical exam was noted to have a continuous cardiac murmur. Transthoracic echocardiogram demonstrated a sinus of Valsalva fistula extending into the right atrium. A transoesophageal echocardiogram (TOE) was then performed to better characterise the abnormality (see panels). The patient underwent closure of the aorto-right atrial fistula with a pericardial patch. The patient had an uneventful postoperative course and was discharged home. Aortic cusp fistulas should be part of the differential diagnosis when a continuous cardiac murmur is auscultated.
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