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BACKGROUND: Ventricular septal rupture (VSR) following acute myocardial infarction is rare in the modern revascularisation era. Nevertheless, clinical awareness is paramount, as presentation may vary.

CASE PRESENTATION: A middle-aged male with no history of cardiovascular disease developed progressive heart failure symptoms while travelling abroad. Initial workup revealed a prominent systolic murmur, but findings were inconsistent with acute coronary syndrome. Transthoracic echocardiogram showed a small hypokinetic area in the basal septum, preserved left ventricular function and no significant valvulopathy. Despite the absence of chest pain, an invasive angiography revealed occlusion of a septal branch emerging from the left anterior descending artery, otherwise patent coronary arteries. Despite administration of diuretics, the patient remained symptomatic and presented two months later to his primary care provider with a persisting systolic murmur. He was subsequently referred to the outpatient cardiology clinic where echocardiography revealed a large VSR involving the basal anteroseptum of the left ventricle with a significant left-to-right shunt. After accurate radiological and haemodynamic assessment of the defect, he successfully underwent elective surgical repair.

INTERPRETATION: Although traditionally associated with large transmural myocardial infarctions, VSR may arise also from minor, subclinical events. A new-onset murmur is a valuable hint for the alert clinician.