A 50-year-old male presented to the Cardiology department due to edema of the legs, erythema, pain, abdominal swelling, and was hospitalized with pulmonary hypertension, right heart failure, atrial fibrillation, chronic obstructive pulmonary disease, and cellulitis. The patient had a history of appendectomy when he was 20 years old and had been stabbed in the abdomen when he was 35 years old. He had been stabbed twice, and 1 h after the stabbing, he had been successfully treated by general surgery. The patient had been discharged 1 week postoperatively. The patient also had a 4-year history of smoking during his adolescent period. Five years earlier, the patient (age 45 years) had presented to the Cardiology outpatient service and was diagnosed with New York Heart Association (NYHA) Class II shortness of breath. On echocardiography (echo), his right heart cavity dimensions were mildly increased and pulmonary artery systolic pressure was found to be 45 mmHg. After treatment, his complaints regressed completely. Three years earlier (age 47 years), he had been admitted to the Pulmonology department with abdominal and bilateral leg swelling, and shortness of breath (NYHA Class III) complaints. CT thorax was performed and he was diagnosed with right heart failure. But dilated IVC was missed or might have been accepted as secondary dilatation to pulmonary hypertension and right heart failure. Intravenous diuretics, steroids, teophylline, and inhaled bronchodilator treatment had been administered. Subsequently, his complaints regressed. His echo findings at that period of time were as follows: Left ventricular ejection fraction 65%, Grade I diastolic dysfunction, normal left heart cavities, significantly enlarged right heart cavities, pulmonary artery systolic pressure 70 mmHg, and Grade 2-3 tricuspid failure. He was being closely monitored by the pulmonologist for pulmonary hypertension. One year earlier (age 49 years), he had been admitted to the Pulmonology department due to newly developed high ventricular rate atrial fibrillation (168 bpm) resulting in significant abdominal ascites, diffuse edema of the lower extremities, and crackles in the middle and lower lung zones (NYHA functional Class IV). At that period of time, the echo had shown normal left heart cavity dimensions, left ventricular ejection fraction 50%, paradoxical interventricular septal motion, significantly enlarged right heart cavities, pulmonary artery systolic pressure 95 mmHg, and Grade 3 tricuspid insufficiency. The patient was started on digoxin 1 x 1 tb, diltiazem 2 x 120 mg, and warfarin by the cardiologist. In 1 week, his symptoms regressed to NYHA Class III and he was discharged from the hospital. Fifteen days later, the patient was admitted to Emergency department with symptoms of worsening right heart failure and shortness of breath; therefore, he was moved to the Cardiology department and started on intravenous furosemide, spironolactone 25 mg, clexane 2 x 0.6 cc (because of subtherapeutic international normalized ratio), and continued on diltiazem and digoxin. According to the dermatologist's recommendation, he was also started on ampicillin/sulbactam 4 x 1 g IV. Laboratory findings were as follows: Blood urea nitrogen 60 mg/dl (normal range 7-22 mg/dl), creatinine 1.2 mg/dl (normal range 0.8-1.3 mg/dl), aspartate aminotransferase 40 U/l (normal range 0-35 U/l), alanine aminotransferase 45 U/l (normal range 0 -35 U/l), hemoglobin 12.8 g/dl (14.0-17.4 g/dl), white blood cells 14,500/microl (normal range 3,500-10,500 microl). On the second day of admission, the patient first developed respiratory arrest and then cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated, the patient was intubated, and on the 5th minute of CPR, he gained basal rhythm of atrial fibrillation and a blood pressure of 100/60 mmHg. The patient was then transferred to the intensive care unit and placed on a mechanic ventilator. With an initial diagnosis of pulmonary embolism, the patient had undergone pulmonary CT angiography; however, no thrombi were detected. Deep vein thrombosis (DVT) protocol CT was not performed. Only thorax CT angiography and lower extremity venous Doppler ultrasonography were performed. But no thrombotic formation was detected at Doppler examination. The diagnosis was missed by physicians. But simple abdominal auscultation revealed the diagnosis. The IVC diameter was found to be 19 cm. On cardiologic evaluation, at the tricuspid focus, on the left and right corners, a harsh pansystolic murmur at 4-5/6 intensity was heard. The liver was palpable 7-8 cm under the costal arch, and diffuse ascites was detected in the abdomen. Edema of the legs was 3+. On the umbilical region of the abdomen, a continuous thrill and a machine-like murmur were detected [Figure 1]. On echo, right cardiac cavities were severely enlarged, and 3-4 degree of tricuspid failure, pulmonary artery pressure of 75-80 mmHg, and normal left heart cavities were detected. IVC was measured and found to be 18 cm. On the region of abdominal murmur, the echo probe showed fistula between the abdominal aorta and the IVC on transverse plane [Figure 2a and b]. Transesophageal echocardiography showed intact interventricular septum and patent foramen ovale of the interatrial septum. Right to left shunt of the patent foramen ovale was seen. CT angiography was performed in order to confirm the ACP and to determine its dimensions. Right at the lower level of renal artery and bifurcation of the aorta, between IVC and abdominal aorta, a fistula was detected. At the localization of fistula on the lower level of the renal artery [Figure 3a], the diameter of the aorta was 22 mm, IVC diameter was 99 mm, and the diameter of the fistula tract was 11 mm. At the localization of fistula on the abdominal aortic bifurcation [Figure 3b], the aortic diameter was 25 mm, IVC diameter was 169 mm, and fistula tract diameter was 17 mm. Hemodynamic work-up and shunt measurements were planned. On abdominal aortography, findings consistent with CT angiography (two fistulas from the abdominal aorta to the IVC) were found [Figure 4]. Oxymetrically calculated left-to-right shunt was 2.8. On coronary angiography, the coronary arteries were normal and systolic pulmonary artery pressure was 75 mmHg [Figure 5]. The patient's condition was hemodynamically stabile; however, considering the possible complications, the ACP was decided to be closed percutaneously. The procedure was to be performed after the pneumonia secondary to intubation had resolved. Despite the antibiotic therapy, the pneumonia did not resolve. The patient developed sepsis and died of septic shock in the intensive care unit.