A 58-year-old male with a past medical history of diabetes mellitus type II, hyperlipidemia, diskitis, and Streptococcus gordonii endocarditis presented to the emergency department with fever and chills. Due to known history of endocarditis, an urgent transthoracic echocardiogram (TTE) was performed which revealed a 2.2 × 1.3 cm tricuspid valve vegetation, 1.7 × 0.3 cm pulmonary valve vegetation, and a quadricuspid aortic valve with mild regurgitation (Figure 1A, B, and D). Transesophageal echocardiogram (TEE) was performed and confirmed a quadricuspid aortic valve and revealed a large aortic root abscess with fistula formation from the right coronary cusp into the right ventricle (Figure 1C, E-G, Figure 2A and B). Surgical intervention confirmed abscess vegetation extending from the right coronary cusp into the interventricular and interatrial septums, creating a large necrotic fistula to the right atria and ventricle (Figure 2C). Extensive cardiac surgery was performed and included composite aortic root replacement, reimplantation of left main coronary artery, right coronary artery bypass grafting, tricuspid valve replacement, and aortic sinus to right ventricle fistula repair with bovine pericardial patch.