CASE PRESENTATION: 43 year old African American male with ESRD and recently diagnosed PE presented to our center in 2015 with dyspnea and positional syncope. He endorsed NYHA class IV symptoms with minimal improvement in shortness of breath from anticoagulation. He was admitted for further workup. Ventilation perfusion scan revealed multiple bilateral defects. Chest x-ray demonstrated the tip of a left HeRO graft in the right atrium. Echocardiography (ECHO) showed normal left ventricular size and function but severely dilated right ventricle (RV) with severe tricuspid regurgitation (TR). A HeRO graft was found coursing through the tricuspid valve with tip visualized in the RV. Further history revealed syncope related to changing positions of left arm. ECHO repeated with left arm maneuvers demonstrated intermittent prolapse of HeRO graft through the tricuspid valve. The thrombosed HeRO graft was removed. A subsequent right heart catheterization showed normal hemodynamics. Follow up pulmonary angiogram revealed resolving thromboembolic disease with decrease in filling defects. HeRO graft was determined to be the source of recurrent thromboembolism as well as intermittent severe TR from intermittent prolapse and probable resultant arrhythmia associated syncope. On reevaluation in 2016, the patient endorsed NYHA class I symptoms without recurrence of PE or syncope.