Forty patients with V.S.D. and coarctation of the aorta were operated on at Department of Cardiac Surgery, Ospedali Riuniti Bergamo. Surgical management of infants with V.S.D. and coarctation depends on the magnitude of the left to right shunt. Patients may therefore be divided into two groups: 1) those with aortic coarctation and a small V.S.D., who have normal or slightly elevated pulmonary artery pressure. If surgery is required, these patients can be successfully treated by repairing the coarctation alone. Ten cases in our series were operated on using this approach without deaths; 2) patients with coarctation and large V.S.D. and pulmonary hypertension. The management of these infants is controversial. One stage repair was used in four cases without deaths. On the other hand, nine out of 11 patients in whom the V.S.D. was left unrepaired at the same operation died, giving a 81.8% mortality rate. Repair of coarctation with simultaneous banding of the pulmonary artery was equally affected by high mortality. With this approach in 13 patients there were seven deaths, giving a 53.8% mortality rate.