The mirror image of Gerbode defect: acquired right ventricular-to-left atrial communication

: Left ventricular-to-right atrial communication, known as Gerbode defect, is rare. However, right ventricular-to-left atrial communication is much rarer. We present a case of a middle-aged woman with a past history of primum atrial septal defect surgery who presented with dyspnea on exertion. Echocardiographic studies showed dehiscence of the pericardial atrial patch from atrioventricular junction, causing a right ventricular-to-left atrial communication with bidirectional shunt. A three-dimensional transesophageal echocardiographic reconstruction revealed a defect of septal tricuspid valve leaflet. In atrioventricular septal defect, the apical displacement of mitral valve insertion, together with a congenital defect of septal tricuspid valve leaflet, contributes to predisposing conditions for this communication.