Doppler color flow mapping in conjunction with two-dimensional echocardiography was used to evaluate ventricular septal rupture after myocardial infarction (seven anterior and eight inferior) in 15 patients and to correlate these findings with cardiac catheterization and surgical or autopsy data. Ventricular septal rupture was diagnosed by turbulent flow transversing the ventricular septum. The direction and velocity of shunt flow was determined by color M-mode and conventional Doppler methods. In all patients, Doppler color flow mapping correctly defined the site of septal rupture, which occurred at areas of discordant septal wall motion or 'hinge points' (six posterior inlet, three anterior inlet, and six apical trabecular septum). Each of three patients with moderate tricuspid regurgitation and three of four patients with right-to-left shunting during diastole died, and all had an elevated right ventricular end-diastolic pressure. Right ventricular wall motion index was significantly higher in the patients who died compared with those who survived (mean ± SEM; 2.8 ± 0.2 vs. 2.0 ± 0.2, p = 0.012), but there was no difference in left ventricular wall motion index. The rupture size measured by Doppler color flow imaging (1.7 ± 0.1 cm) correlated with the size determined during surgery or autopsy (1.8 ± 0.2 cm, r = 0.68, p = 0.022) and the pulmonic-to-systemic shunt flow ratio by cardiac catheterization (2.4:1 ± 0.3, r = 0.74, p = 0.004). Color-guided continuous-wave Doppler estimates of right ventricular systolic pressure (47 ± 2 mm Hg) correlated with cardiac catheterization measurements (48 ± 3 mm Hg, r = 0.90, p = 0.0002). Two-dimensional echocardiography combined with Doppler color flow maping allows detection, evaluation, and prognostication in ventricular septal rupture.