Pulmonary arterioplasty (PA plasty) is sometimes performed during a type of heart surgery called bidirectional cavopulmonary anastomosis (BDCA), but it has been linked to higher complication rates. This study looked at over 500 patients who had BDCA, some with PA plasty and some without, to see how it affected long-term outcomes. While patients who had PA plasty needed more follow-up procedures on their pulmonary arteries, survival to the final stage of heart reconstruction was similar for both groups. Importantly, by the time patients reached the final surgery (Fontan procedure), pulmonary artery growth and blood flow pressures were healthy, and hospital outcomes were comparable. These findings suggest that PA plasty does not increase the risk of death and allows for proper artery development, despite requiring additional interventions along the way.