We prospectively employed a risk-stratified approach to first-stage palliation of hypoplastic left heart syndrome. High-risk features included severe tricuspid insufficiency, severe right ventricular dysfunction, a severely restrictive or intact atrial septum, an ascending aortic diameter ≤2 mm, late presentation, weight <2 kg, or significant extracardiac issues, Infants without high-risk features underwent a Norwood procedure (with Sano modification), whereas infants with high-risk features underwent a hybrid procedure consisting of bilateral pulmonary artery banding, ductal stenting, and atrial septostomy or a Norwood/Sano. Operative survival for 10 infants without high-risk features undergoing a Norwood/Sano procedure was 90%. Operative survival for 5 infants with high-risk features undergoing hybrid palliation was 100%, compared to 29% in 7 infants with high-risk features undergoing the Norwood/Sano procedure. Although only short-term data are available, this hybrid palliative procedure may have a role for infants with hypoplastic left heart syndrome and high-risk features.