This week we review a landmark paper reviewing the very large experience of Dr. Hanley and his team at Stanford University in managing VSD/PA with MAPCA's. What advantages are seen with the 'midline unifocalization' approach popularized by this team over the past 20+ years? Is this an approach that can be broadly applied or are the technical operative skills too challenging for most? Why are these operations so difficult? How does the Stanford team decide who is a candidate for a single operation and who is not? We explore many of these topics and others with Surgery Professor Richard Mainwaring of Stanford University who is the first author of this important paper published recently in JTCVS. You will not want to miss Dr. Mainwaring's insightful commentary on the challenges and potential benefits of this very complex and painstaking approach. doi: 10.1016/j.jtcvs.2018.03.153.