Introduction: Ventricular septal rupture is a rare but oft en lethal complication of myocardial infarction (MI). Methods: A 71 year old man with no medical history was admitted with anterior MI. Emergency coronary angiography revealed 2-vessel disease, unsuitable for percutaneous intervention or surgery. Echo showed major wall motion abnormalities with apical aneurysm, EF of 25% and multiple apical thrombi. Treatment was initiated with DAPT, UFH and oral anticoagulation. The next day echo revealed an apical ventricular septal rupture with left -to-right shunt, severe tricuspid regurgitation and circumferential pericardial effusion. Conservative treatment is chosen considering the high surgical risk. One week after the patient developed hematochezia with an acute drop of hemoglobin of 3.5 g/dl. Upper endoscopy showed a gastric ulcer with adherent clot and multiple antral ulcers, but no active bleeding. Results: Antiplatelet and anticoagulant therapy was interrupted, while 5 units of erythrocyte mass and 2 units of fresh plasma, continuous IV PPI and oral sucralfate were administered. Endoscopic re-assessment aft er 3 days of therapy showed no active bleeding or fresh clot. The patient remained symptomatic but stable in heart failure class NYHA 2-3. Echo at 1 and 3 months showed persistent ventricular rupture, but stable EF, and organized small LV thrombi. Conclusions: This is a frequent situation of a patient with severe complications after a MI who became clinically stable only under medical treatment. Aggressive medical management of no-option patients might be successful whenever surgical risk is considered too high.