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The era of pediatric cardiac surgery began when Walton Lillehi performed the first successful procedure for closure of ventricular septal defect using the patient's mother as cross-circulation. Despite significant advances in cardiopulmonary bypass (CPB) techniques, there are unknown risks associated with CPB that led physicians to devise new ways to avoid it. Minimally invasive surgery and percutaneous techniques have progressed significantly; more and more hybrid procedures are being employed to optimize patient care. The full range of side-effects of CPB in the pediatric population remains unknown, and their severity may be related to the length of CPB as well as the patient's age. It can be speculated that in children who are in a developmental stage, the effects may be worse than in an adult. ¹ The pioneering work of percutaneous pulmonary2, 3 and aortic valve placement is well known. There are, however, some limitations of the pulmonary valve procedures in the pediatric population. These procedures require a large sheath size and may be difficult or not feasible in patients with smaller body surface area. In addition, some patients have a very dilated pulmonary outflow tract and would require valves that are larger than those being investigated. 5 Perventricular closure of ventricular septal defects was introduced by us in 1997 and published in 1998.6, 7 It is now an accepted hybrid procedure for closure of difficult ventricular septal defects in small patients where percutaneous closure is not feasible or increases the chance of complications. 8

Pulmonary valve placement is recommended in patients with severe pulmonary insufficiency …