In total anomalous pulmonary venous drainage (TAPVD) all pulmonary veins return to the right-sided venous system, either to the right atrium or coronary sinus, or to superior or inferior vena cava or the hepatic veins. This is a L → R shunt lesion with mixing through an intra-atrial communication. Symptoms depend on the intracardiac shunt and degree of obstruction. Anaesthetic management can be challenging and high risk, balancing shunt volume by avoiding decrease in pulmonary vascular resistance with air and mild hypoventilation as well as avoiding an increase in systemic vascular resistance.