The patient was a 19-year-old male who had complex congenital heart disease with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (MAPCAS). He underwent serial unifocalisation of unilateral MAPCAS to pulmonary homograft tubes with arterial pulmonary shunt supply. Anatomical correction was achieved by removal of arterial shunts, application of a Dacron tube graft to the homograft tubes, which was connected to a 20-mm Hancock bioprosthesis pulmonary valve associated with ventricular septal defect closure at age 7 years. Later in life, he developed right pulmonary artery stenosis and pulmonary valve stenosis. Right pulmonary artery stenosis was treated with a tissue patch and balloon expandable stent. Pulmonary valve stenosis was treated with balloon dilatation. A subsequent attempt at right ventricular outflow tract (RVOT) reconstruction with a pulmonary homograft failed, due to suture line rupture secondary to high RV pressures (90/12 mmHg). This required emergent surgery for a RV-pulmonary artery conduit change with a 22-mm Contegra conduit. Major aortopulmonary collateral arteries is one of the most challenging conditions to manage. Reconstruction of the RVOT may require pulmonary valve replacement with a cryopreserved homograft or bovine jugular vein graft (Contegra) during primary repair or re-operation. One study showed that although survival and freedom from distal stenosis were similar between the two conduits, freedom from failure, dysfunction, and explantation were better with Contegra conduits in patients needing RVOT reconstruction. Furthermore, choice of RV-pulmonary artery conduit must take into account the pulmonary artery pressure, with a pulmonary homograft contraindicated with PAP >50 mmHg.