Post–myocardial infarction (PMI) ventricular septal defect (VSD) repair is associated with high mortality.^1,2 The pathophysiology varies based on the size of the infarction and the VSD, which results in a left-to-right systemic-to-pulmonary shunt (Q_p/Q_s = shunt fraction), pulmonary edema, and decreased systemic blood flow, with cardiogenic shock (CS) in 50% of patients.^1,2 Repair was historically performed by direct Dacron patch closure of the VSD, and the intra-aortic balloon pump (IABP) was routinely used for mechanical circulatory support (MCS). However, the IABP has minimal impact on the Q_p/Q_s pathophysiology, and the mortality exceeded 35%.^1,2 The David repair technique was an important advance that resulted in improved outcomes, as it excludes the infarcted septum and VSD, remodels the left ventricle, and avoids placement of repair sutures in the necrotic septum.³ The development of advanced techniques in MCS, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the microaxial flow pump (MFP), has improved prerepair hemodynamic stabilization of patients, and these devices have been used as bridges to definitive repair in patients presenting with CS.^4,5 This study reviews our experience with surgical repair of PMI-VSD, with a focus on our strategic use of MCS.