Ventricular septal defect, complicating acute myocardial infarction, remains one of the most challenging cases for surgeons. The patients are acutely ill, often in cardiogenic shock. Their myocardial tissue is fragile and does not hold sutures well. The mortality rate is high. A variety of surgical techniques have been developed with mixed results. Newer technologies, such as mechanical circulatory assist devices and septal occluders, provide novel strategies. In this issue, Asai et al. describes their experience of surgical repair of this difficult entity, in which the defect is repaired through a right ventriculotomy. Of note, the illustrations and videos were created by Dr. Asai himself.
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