The authors report the case of a 73-year-old male with an inferior myocardial infarction and right ventricular dysfunction, evolving in Killip class IV. On the third day in the ICU cardiogenic shock ensued and septal rupture was diagnosed. Despite the severity of the setting and the poor prognosis, it was decided to operate. Intraoperative transesophageal echocardiography (TEE) disclosed a complex inferior septal rupture that was successfully repaired with a patch by the infarct exclusion method. Postoperatively, there was recurrence of the shunt with hemodynamic instability and a redo operation was programmed. Intraoperative TEE showed a partial tear of the anterior aspect of the patch and the suture was restored. The patient was discharged 45 days following admission, after transthoracic echocardiography (TTE) showed the integrity of the patch suture and full recovery of right ventricular function.