Background Ventricular septal rupture (VSR) is an uncommon but potentially fatal complication of acute myocardial infarction (AMI). The management of VSR is challenging, and its surgical correction is associated with the highest mortality among all cardiac surgery procedures. Case summary A 57-year-old man with a history of smoking presented with AMI with a large apical VSR in addition to a large secundum atrial septal defect (ASD). His left ventricular ejection fraction was 30%, and the right ventricle was moderately dilated with normal systolic function. Cardiac catheterization revealed that the left anterior descending artery was diffusely diseased with total mid occlusion, whereas other coronary arteries had non-obstructive disease. This unique combination resulted in distinctive presentation with paradoxically better outcomes. After stabilization, the patient’s interventricular septum was reconstructed, and the ASD was closed with a pericardial patch. The post-operative period was uneventful, and the patient was discharged 1 week after surgery. A follow-up echocardiography revealed no residual shunt. Discussion Post-myocardial infarction VSR presents differently in patients with pre-existing right ventricular volume overload. In such cases, the absence of significant cardiogenic shock at presentation may result in better surgical outcomes. Myocardial infarction , Ventricular septal rupture , Atrial septal defect , Cardiogenic shock , Case report Learning points Post-myocardial ventricular septal rupture (VSR) is rare but potentially fatal complication. Surgical correction carries highest mortality among all cardiac surgical procedures. Clinical presentation predicts the outcomes. Elevated right heart pressures serve as protective mechanism in case of post-myocardial infarction VSR.