We performed 13 operations on 12 elderly patients with ventricular septal defect (VSD) following myocardial infarction. All patients were older than 65 years (range 66 to 82 years) and six were over 70 years of age. Ten underwent operation, with counterpulsation support, within 3 weeks of development of the VSD. Among eight patients with anteriorly located VSDs, there were four survivors. Among four patients with inferior defects, three survived. Overall hospital survival was 58%. Hospital costs were no greater in the elderly than in younger patients. The seven long-term survivors were followed up for from 10 months to 7.5 years (mean 3.9 years). There was one sudden death at 7.5 years in a previously well man. Of the remaining six patients, five are in New York Heart Association Class I, and one is in Class II. One woman, now 84 years old, lives independently over 2 years after repair. Our experience with respect to management suggests that unless medical therapy results in continued improvement rather than stability alone, hemodynamic deterioration is inevitable, and survival for delayed repair is unlikely. Furthermore, undue delay frequently results in renal failure and severely compromises the chances for survival after repair in the acute state.