This case shows that careful clinical assessment is of paramount importance to give a guideline for further diagnostic work up with sophisticated imaging techniques. On cardiac auscultation, the female asymptomatic patient presented a systolic-diastolic murmur with maximum loudness over the left ventricular apex. These sound were more pronouced in the supine position than in prone position. Auscultation was diagnostic for a fistula. However, a first echocardiogram did not reveal any abnormality. The patient was subsequently referred for a diagnostic workup with CMR. On auscultation, the describe  fistula characteristic murmur could be heard easily.  Echocardiography was subsequently directed to a short axis left ventricular scan around the left ventricular apex, as directed by the clinical findings. The ultrasound examination showed a intrahepatic, subdiaphragmatic pathologic and abnormally dilated vessel with a pw doppler finding exactly corresponding to the ascultation. Therefore, clinical findings and echocardiography were suggestive for a arterio-venous fistula in the liver. This interpretation could be nicely confirmed by CMR. View the images now.