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Management of pulmonary atresia with VSD is a difficult task negotiating varied anatomical and physiological obstacles for establishing adequate pulmonary blood flow. In underweight infants where surgical palliation has its own challenges, pulmonary valve perforation and RVOT stenting offers a physiological pathway for maintaining adequate pulmonary blood flow in selected subset with membranous pulmonary atresia. We present a case of successful pulmonary valve perforation with RVOT stenting to establish the antegrade pulmonary flow in a sick underweight infant.