In children with pulmonary atresia not amenable to initial complete correction, antegrade pulmonary blood flow can be established with surgical right ventricular outflow tract (RVOT) patch enlargement. An 11-year experience with RVOT transannular patch (TAP) augmentation without the use of cardiopulmonary bypass (off-pump) is reported. From March 1993 to October 2004, off-pump surgical RVOT enlargement with a TAP was attempted in all patients in whom a concurrent procedure that required bypass was not required. The procedure was performed with cardiopulmonary bypass standby. Twenty-two consecutive patients in whom this procedure was attempted were reviewed. Twenty of 22 patients tolerated off-pump TAP placement. In 2 patients with ductal-dependent pulmonary blood flow, off-pump TAP placement was not tolerated. Adequate antegrade pulmonary blood flow was achieved in all patients without operative mortalities or complications. There was one death in the postoperative period from myocardial ischemia secondary to right ventricular-dependent coronary circulation. Transannular RVOT patch augmentation can be performed safely and effectively without cardiopulmonary bypass.