Medical treatment of postinfarction ventricular septal rupture carries a high mortality. Delayed surgery can be done with good results but many patients die awaiting operation. In 1978 we decided that all such patients presenting to us should undergo urgent cardiac catheterization and surgery. Since then we have seen 22 such patients. Two decided against surgery and died in the hospital. Twenty agreed to surgery; in 15 of these an intra-aortic balloon pump was inserted before catheterization and in another four at the time of operation. Catheterization was performed without complication, and surgery was performed within 2 days of septal rupture in all 20 patients. Twelve patients (60%) survived hospitalization. Three patients died of pump failure shortly after surgery; five died after a second operation for free wall rupture (n = 2) or persistent or recurrent septal defect (n = 3). Two other patients survived reoperation. Survivors were significantly younger than nonsurvivors and had a higher cardiac index and a lower shunt ratio. At a mean follow-up of 47.9 months, there has been one late noncardiac death. Eleven patients survive, all in class I or II. We conclude that in patients with septal rupture urgent surgery results in improved near-term survival compared with known survival rates in medically treated patients. Early recurrent rupture is common and often disastrous and requires refinement in operative technique. Age, cardiac index, and shunt volume are related to surgical outcome. Hospital survivors do very well on a long-term basis. We recommend continuation of this aggressive approach.