An infant with pulmonary atresia and intact ventricular septum is presented who, after initial patch reconstruction of the right ventricular outflow tract and bidirectional cavopulmonary anastomosis through a fifth median sternotomy, underwent an echocardiographically guided closed atrial septotomy, which resulted in marked long-term clinical improvement. The technique of intraoperative transesophageal echocardiography as used in the presented case represents an expanded role for this diagnostic modality in congenital cardiac surgery.
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