Optimal timing of surgical intervention for post-myocardial infarction ventricular septal rupture: A comprehensive evidence review

Background Ventricular septal rupture (VSR) is a rare but devastating complication of acute myocardial infarction, historically associated with extremely high mortality rates. The optimal timing of surgical repair-balancing the risks of operating on friable, acute necrosis against the dangers of progressive cardiogenic shock during a waiting period-remains a central clinical dilemma. Methods A systematic narrative review was conducted following PRISMA guidelines. PubMed/MEDLINE, Embase, and Cochrane Library databases were searched from 2000 to 2024 for studies comparing early (≤7 days) versus delayed (>7 days) surgical repair of post-MI VSR. Data were extracted on patient characteristics, mechanical circulatory support (MCS) use, surgical techniques, and clinical outcomes, including operative mortality, reoperation rates, and long-term survival. Results Evidence from contemporary observational studies confirms that delayed surgical repair is associated with significantly lower operative mortality compared to early repair, primarily due to superior tissue integrity and lower rates of residual shunt. However, this mortality gap has substantially narrowed in the contemporary era with routine use of advanced MCS, particularly veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella devices. These technologies enable hemodynamic stabilization, transforming early repair from a salvage procedure to a more controlled intervention. Modern management has evolved from a rigid temporal dichotomy to a patient-tailored strategy emphasizing immediate stabilization, risk stratification, and selective MCS bridging to the optimal surgical window. Conclusion While delayed repair remains preferred for hemodynamically stable patients, early repair supported by advanced MCS represents a viable and often necessary strategy for patients with refractory shock. The decision paradigm has shifted toward “stabilize, support, then repair,” requiring multidisciplinary heart team collaboration. Future directions include standardized MCS protocols, validated risk scores, and exploration of hybrid percutaneous-surgical approaches to further improve outcomes for this high-risk population.