Optimal Surgical Timing After Postinfarction Ventricular Septal Rupture: A Narrative Review With a Proposed Heart Team Decision Algorithm

Postinfarction ventricular septal rupture is a rare, frequently lethal mechanical complication of acute myocardial infarction, and the optimal timing of repair remains controversial. Early surgery is often unavoidable in refractory shock but is technically hazardous because necrotic, friable myocardium provides poor suture support. Delayed repair after tissue maturation is associated with lower operative mortality, although this apparent benefit is substantially inflated by survivorship and immortal time bias. Mechanical circulatory support, including intra-aortic balloon counterpulsation, venoarterial extracorporeal membrane oxygenation, and microaxial flow pumps, may stabilize selected patients, permit end-organ recovery, and bridge them to later repair. However, available evidence is almost entirely observational, and the certainty supporting major timing and device selection recommendations is low or very low. This narrative review synthesizes the biological basis of timing, diagnostic and anatomic considerations, surgical and transcatheter options, mechanical support strategies, and transplantation. We propose a practical Heart Team framework based on hemodynamic status, tissue maturation, rupture anatomy, and daily reassessment, with explicit clinical triggers for abandoning delay. Surgical timing should therefore be individualized according to physiology rather than dictated by a fixed chronological threshold, pending prospective multicenter validation.