Infective endocarditis (IE) in children it is serious condition and has a hospital mortality rate 10-20 % with medical treatment. Although, surgical management is the last chance for severely ill patients and has been associated with a mortality rate of 50 %. This is a case report of a child 10 years old with aortic IE who developed coronary syndrome intraoperatively. A 10-year-old boy with history of aortic valve repair 6 years ago was recently diagnosed with aortic endocarditis. He was transferred to the cardiac center for treatment. Clinically, he was unwell, pale and complaining of chest pain days before the surgery. He was admitted with electrocardiography changes, ST depression DI-II, V5 and V6.Echocardiogram revealed a mobile mass on the aortic valve which prolapsed into the left ventricle during diastole causing severe aortic regurgitation. Heparin anti-coagulation was instituted upon arrival. He received meropenem and teicoplanin for 5 days and was transfused before surgery. He underwent urgent aortic replacement due to the mobile mass on the aortic valve, unresolved EKG changes and increasing heart failure. Intraoperatively during repeat sternotomy and lysis of adhesions he developed worsening coronary syndrome (increase of previous ST depression DI-II and more III). Hypotension and bradycardia developed which did not responded to atropine. Pulseless electrical activity ensued, and open cardiac massage and paediatric advance life support was performed for 25 minutes before establishing cardiopulmonary by-pass (CPB). During CPB he developed increasing of metabolic acidosis, lactate and decreased of urine output less than 0.9 ml/kg/h. Aortic valve replacement with 19 mm mechanical valve was done during hypothermia 28 degrees. Following release of the cross-clamp no electrical activity occurred and was connected to the pacemaker VVI for 3 hours and worsening of lactic acidosis (lactate 17),urine output decreasing and creatinine increasing. Disconnection from CPB was done and the patient died. Surgery was performed in a resource restricted low- and middle-income country Figure 1.Mid esophageal AV Long Axis View (ME AV LAX) 110 degrees: significant size mass attached to right size of aortic valve, moving, creating severe insufficiency. Figure 2.Deep Transgastric Long Axis view (Deep TG LAX) 120 degrees, showed opening of aortic valve, thickened and dysplastic. Significant jet from aortic regurgitation with significant size vegetation and showed LV severe dilated with moderate to severe impairment.