Perventricular Melody valve placement has been described as a bailout approach or alternative RVOT approach in patients >30 kg. We present three patients <20 kg and two patients with limited venous access, where we electively performed the perventricular approach. Retrospective analysis of patients <30 kg and vascular access limitation undergoing elective hybrid pulmonary valve replacement were reviewed. The subcostal approach was performed without sternotomy with the sheath introduced through the diaphragmatic surface of the right ventricle. Diagnoses included tetralogy of Fallot (n = 3) and truncus arteriosus (n = 2). Mean weight was 16.2 kg (range 4.7–28.1 kg). Four patients had RV–PA conduits (size: 14–21 mm), and the fifth patient had a transannular patch. All patients met criteria for surgical valve replacement. Technical success was 100%. In two patients with absent pulmonary valve, the stent migrated during advancement of the delivery sheath. These stents were anchored in the distal main pulmonary artery (n = 1) or branch pulmonary artery (n = 1) without sequela. Tricuspid valve chordal injury occurred in one patient, where transesophageal echocardiogram (TEE) was not utilized. No patient required conversion to cardiopulmonary bypass. One patient with absent pulmonary valve died on follow-up as a consequence of severe airway compromise. Our initial experience demonstrates that the perventricular valve can be placed safely in small-sized patients. Advancement of the melody ensemble may be difficult and may cause stent migration. We conclude that the technique is feasible in small-sized patients and that prevention of complications includes placement of the stent at the time of the valve and TEE assistance in reducing tricuspid valve injury.