Abstract
This hemodynamic round section deals with severe pulmonary arterial hypertension with suprasystemic pulmonary artery pressures in a patient who underwent delayed surgical correction of the double-outlet right ventricle with a large subaortic ventricular septal defect (VSD). Recreation of a moderate-sized VSD by electrocautery-aided fenestration of the surgical patch resulted in effective right ventricular decompression. The changes in the hemodynamics are illustrated in the pressure traces and Doppler echocardiographic images. The changes in cardiac events on the right and left heart due to the right bundle branch block are also illustrated in the manuscript.