This study assesses the long-term results of emergency surgical repair of postinfarction ventricular septal defect (VSD). The cases of 28 patients surviving early operative closure of septal rupture (within 1 day to 20 days of the infarction) were reviewed. Only 1 had concomitant coronary artery bypass grafting. Follow-up ranged from 7 to 16 years with an average of 9 years. Four patients were lost to follow-up. There were 4 late deaths, 2 of which were of cardiac origin. One was due to congestive heart failure and 1 to arrhythmia, 1 and 6 years after operation, respectively. Of the remaining 20 patients, 8 are in New York Heart Association Functional Class I and 12 are in Class II. Two patients underwent reoperation, 1 for a left ventricular false aneurysm 5 years postoperatively and the other for unstable angina 10 years postoperatively. Both had an uneventful postoperative course. Only 2 patients had late coronary events (1, nonfatal myocardial infarction; 1, unstable angina). We conclude that aggressive management of postinfarction VSD is fully justified in view of the long-term survival and functional palliation that can be anticipated for operative survivors. We advocate that preoperative coronary artery angiography and subsequent bypass grafting be performed on a selective rather than routine basis. © 1987, The Society of Thoracic Surgeons. All rights reserved.