Recognition and treatment of patients with ventricular septal rupture following infarction have improved over the past 25 years to the extent that survival with good long-term palliation is achieved in the majority of patients treated surgically for this catastrophic complication of acute myocardial infarction. The small minority of patients who, by the process of selection, are seen for surgical correction of septal rupture several weeks after infarction routinely have repair of the septal defect with an operative risk of less than 10%. With increasingly early diagnosis of septal rupture, the majority of patients are seen for consideration of surgical repair often within hours after septal rupture. Most such patients seen early after septal rupture exhibit cardiogenic shock. Refinement of operative techniques both for suture repair of freshly infarcted myocardium and for repair of defects in different anatomical locations has markedly improved survival in these critically ill patients. Deferral of operation for the patient in cardiogenic shock after septal rupture represents a failed therapeutic strategy. Conversely, emergency operation for the patient with septal rupture and cardiogenic shock has markedly improved survival in this high-risk group. Prolonged intraaortic balloon pump support and deferred operation should be reserved for the uncommon patient who, because of delayed diagnosis or referral, is seen in an advanced stage of multisystem failure in which the risks of early operative intervention involve the function of organs other than the heart.