A 67-year-old female, who had a successful Whipple’s procedure 8 years ago for Stage 1b pancreatic adenocarcinoma, presented to our hospital with a 1-day history of left-sided chest pain, accentuated with coughing, and shortness of breath, orthopnoea, and paroxysmal nocturnal dyspnoea. Her past medical history included hypertension (treated with amlodipine 5 mg (once daily) and telmisartan/hydrochlorothiazide 80–12.5 mg (once daily)), chronic obstructive pulmonary disease (treated with Umeclidinium bromide inhaler 62.5 μg 2 puffs (twice daily)), and mood disorders for which she was on the appropriate treatment. She was hypoxic at 92% on 4 L of oxygen, afebrile, with an elevated jugular venous pressure and 3/6 holosystolic apical murmur. Chest auscultation revealed bilateral lung base crackles. Her initial blood work revealed a marginally elevated white blood cell count 11.65 × 109/L (normal range: 4.00–11.00 × 109/L) with neutrophils 8.49 × 109/L (normal range: 1.50–7.50 × 109/L), haemoglobin 130 g/L (normal range: 110–160 g/L), platelet count 138 × 109/L (normal range: 150–400 × 109/L), International Normalized Ratio 1.2 (normal range: 0.8–1.2), partial thromboplastin time 27 s (normal range: 27–39 s), troponin T 292.2 ng/L (normal value < 14 ng/L), and brain natriuretic peptide 1581 ng/L (normal value < 300 ng/L). A transthoracic echocardiogram (TTE) demonstrated a free-floating 1.1 cm × 1.7 cm mobile mass () attached to the anterior mitral valve leaflet associated with moderate mitral regurgitation (). Her symptoms were felt to be associated with the mitral regurgitation found on the echo. She had preserved left ventricular systolic function. Transoesophageal echocardiogram (TEE) revealed an additional mobile mass on the posterior mitral valve leaflet and a patent foramen ovale. Infective endocarditis was suspected, and the patient was started on empiric broad-spectrum antibiotics. However, three consecutive sets of blood culture did not reveal any growth including for Brucella, Bartonella, and Coxiella. Based on the high pre-test probability for infective endocarditis, antibiotics were continued for possible culture-negative endocarditis. Computed tomography-pulmonary angiogram (CT-PA) and CT abdomen and pelvis showed no pulmonary embolism; however, mediastinal and hilar lymphadenopathy, a soft tissue lesion in the left lateral 8th rib (), and splenic and left renal infarcts () were identified. Computed tomography brain revealed a right occipital lobe infarct. Cardiolipin G and M antibodies and rheumatoid factor were assessed for the multiple infarcts, but were negative. Biopsy of the chest wall lesion (), which was found on CT-PA, revealed a poorly differentiated invasive adenocarcinoma consistent with pancreaticobiliary origin. In view of the above results, a diagnosis of NBTE secondary to metastatic pancreatic disease was established. Mitral valve surgery or therapies for her metastatic disease were ruled out because of her worsening general health condition. Despite aggressive heart failure therapy, she remained oxygen dependent and with worsening of her overall health status, the patient expressed the desire to have comfort care only and died within 28 days of her presentation.