We describe a man with the Marfan syndrome and a prior ascending aortic aneurysm resection who presented with knee pain and concern of endocarditis. Transesophageal echocardiogram showed no vegetations, and computed tomography angiogram of the heart showed a possible pseudoaneurysm. Cardiac catheterization and aortogram revealed the diagnosis of an aorto-right atrial fistula, which was then operatively repaired. This case highlights the role that cardiac catheterization with aortogram can play in the detection of aorto-atrial fistula. CASE REPORTA 49-year-old morbidly obese (body mass index 41 kg/m 2 ) white man with the Marfan syndrome who previously had an ascending aneurysm repair with Bentall procedure at age 38 and aortic valve replacement (St. Jude Medical mechanical prosthesis), gastric bypass, and bilateral knee replacements presented with left knee pain. Th ree weeks prior to admission, he developed worsening left knee pain associated with subjective fever. Th e left knee was painful with motion, swollen, and erythematous. Due to concern of endocarditis, a transthoracic echocardiogram was obtained, which showed no evidence of vegetation. A transesophageal echocardiogram was then obtained, which showed a possible ascending aortic pseudoaneurysm. Computed tomography of the heart revealed a thin linear density within the lumen of the left and right sides of the ascending aorta along the course of the graft, concerning for possible pseudoaneurysm, and also depicted possible dilation of the left main coronary artery. A cardiology consult was requested, and physical examination revealed loud systolic and diastolic murmurs. Th e patient underwent right and left heart catheterization, which showed a mean pulmonary capillary wedge pressure of 22, pulmonary artery pressure of 55/22/32, right ventricular pressure of 55/10, and mean right atrial pressure of 10 mm Hg. Two separate oxygen saturation runs were unable to show any clear evidence of an intracardiac shunt; however, an ascending aortogram (left anterior oblique with mild cranial angulation projection) discovered the presence of a fi stula between the ascending aorta and right atrium (Figure 1). Th e patient's coronary arteries were normal; no left main abnormalities were identifi ed.Th e patient was taken for repeat repair of the ascending aorta and closure of the aorta-right atrial fi stula. Intraoperative transesophageal echocardiogram showed the fi stula with the anterior surface of the ascending aortic graft communicating to the right atrium (Figure 2). Th ere was a pseudoaneurysm of the aortic root with evidence of old thrombus adhered to the aortic wall. A previously implanted composite graft was explanted, and the aortic root was reconstructed with an aortic homograft. Th e right and left coronary buttons were reimplanted and a distal anastomosis was created between the homograft and the ascending aorta. Th e aorto-right atrial fi stula was identifi ed and successfully closed with a bovine pericardium Peri-Guard patch. Th e patient was weaned off ca...

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