A patient in their 20s, with no known past medical history was brought into the emergency department by EMS, after the patient found unconscious by a friend. When evaluated in the emergency department (ED) after ED providers had transferred care to critical care team, patient stated that they remembered injecting drugs, before losing consciousness, but that they woke up in the ED after Naloxone was given. Patient was tachypneic, tachycardic, febrile and hypotensive (with wide pulse pressure) on presentation and was started on vasopressors (norepinephrine) after fluid resuscitation. Physical exam was remarkable for a decrescendo early-diastolic blowing murmur that was heard throughout the chest, bounding pulses and multiple necrotic skin lesions on all extremities with injection scars. Infective endocarditis was highly likely on differential diagnosis at this time, based on Duke’s criteria. On admission, patient was started on broad spectrum antibiotics; Vancomycin, which covers gram positive bacteria including methicillin resistant Staphylococcus aureus and Piperacillin and Tazobactam, which covers gram negative bacteria including Pseudomonas aeruginosa, gram positive as well as anaerobic bacteria. After two blood cultures came back positive for gram positive cocci in clusters, antibiotics were changed to high dose Daptomycin for definitive treatment of IE caused by Staphylococcus aureus. Transthoracic echocardiography (TTE) was performed on admission which showed severe aortic insufficiency (AI) with early closure of the mitral valve, interatrial septum bowed towards the right, with mildly reduced left ventricular ejection fraction, but with no vegetations. Transesophageal echocardiography (TEE) was recommended and was then performed. TEE showed extremely severe AI (Fig. 1–4) with pressure half time of 37msec, 1.6 x 0.8cm para-AV abscess that is adjacent to the right and non coronary cusps (Fig. 5), just distal to the tricuspid valve. A shunt was also noted from aortic root to right ventricle via colour doppler (Figs. 6 and 7). There was also 0.7cm vegetation on the right coronary cups and 1.1 cm vegetation on the non-coronary cusp of the AV. The vegetations on the non and right coronary cusps caused prolapse of the aortic valve (Fig. 8). Cardiothoracic surgery in the hospital was consulted, but due to the complexity of the case also requiring aortic root graft, patient had to be transferred to another hospital. Patient was then informed of these findings, while arrangements were being made to possibly transfer the patient. A few hours later, patient went in to cardiac arrest, requiring two cycles of cardiopulmonary resuscitation and Epinephrine twice. Patient was in pulseless electrical activity during this episode. ROSC was achieved, but mental status on Glasgow Coma Scale was < 8. Patient was still transferred to another hospital, where cardiothoracic surgery accepted the patient to perform surgery, but patient passed away a few hours after getting to that hospital.