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A 74 year old woman presented with cardiogenic shock and a ventricular septal defect (VSD), four days after an undiagnosed inferior myocardial infarction. An infero-apical VSD was repaired using a 4 × 3 cm Dacron patch during emergency cardiopulmonary bypass. Despite postoperative ventilation, balloon pump, and inotropic support she remained hypotensive and oliguric on …