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Front Lines of Thoracic Surgery 30 weeks after their initial acute event. It was these experiences that set the foundation for the belief that operative management should be delayed as long as possible to allow for scarring of the necrotic myocardium to provide for a more stable repair. As experiences grew -in terms of the initial diagnosis and surgical management -early repair was advocated, particularly in patients who were stable before hemodynamic deterioration and subsequent end-organ failure. Clinical presentationThe incidence of PI-VSD has decreased considerably over the years with advances in myocardial reperfusion strategies. Historically, up to 5% of all myocardial infractions were associated with mechanical complications such free-wall rupture, papillary muscle rupture, and PI-VSD (Agnihotri, 2008). With current treatment algorithms that advocate early and aggressive attempts at revascularization of the acute ischemic myocardial -such as thrombolytic therapy, early percutanous interventions with coronary stenting (PCI), and, less frequently, emergent coronary artery bypass surgery (CABG) -the overall incidence has dropped significantly. Large multi-centers studies evaluating the pathophysiologies of acute myocardial infarctions have shown a current incidence of approximately 0.2% of all AMI. With delays in therapies, or late clinical presentation, and the resulting increase in myocardial damage, this incidence increases up to 2%. Despite the relatively low risk of developing a PI-VSD, it account for a disproportionally high risk of mortality. Over 5% of all early deaths after AMI are attributed directly to the pathophysiologic complications of PI-VSD (Poulsen, 2008). The timing of the development of a PI-VSD can be quite variable with the average time to clinical presentation is between 2 and 4 days, however presentation can be as few as a few hours after AMI or as long as several weeks. Patient risk factors include gender, with men at a greater risk than women (3:2 ratio), increasing age, and current smoking history. The mean age of presentation in GUSTO was 62.5 years and ranged from 44 to 81 years (Crenshaw, 2000).