The patient, one of the twins, presented with respiratory distress immediately after birth. Post-admission echocardiography indicated: ventricular septal defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA). After conservative treatment with ibuprofen to promote arterial duct closure combined with cardiac function support and mechanical ventilation, the arterial duct did not close. The respiratory and circulatory functions were not improved either. Multidisciplinary consultation suggested: PDA ligation under non-extracorporeal circulation first, and then VSD and ASD repair should be done when right. The anesthetic management of PDA ligation in these infants should be based on the physiological characteristics of extremely low birth weight infants and the pathophysiology of patent ductus arteriosus, maintaining age-appropriate heart rate and blood pressure during surgery to ensure perfusion of vital organs. Strengthen ventilation management to avoid hypoxia and acidosis and pay attention to perioperative temperature management.