A 1month 8 days old female child was admitted in the Pediatric cardiology department of Dhaka Shishu (Children) hospital with the complaints of severe respiratory distress and cyanosis. Since the baby was delivered at home in a rural area of the country by normal vaginal delivery, they could not seek help immediately from a tertiary level hospital. Subsequently they were referred to Dhaka Shishu (Children) Hospital Pediatric Cardiology department. As the baby was cyanosed and gradually desaturating the cardiology arranged a quick evaluation which revealed Spo2 65%, chest X ray shows ground glass opacity on both lung field, specially right lung field was not totally visible, and Trans-thoracic Echocardiography revealed a large almost 6 mm diameter Patient Ductus Arteriosus with predominant left to right shunt, severe pulmonary hypertension (PA pressure 65 mm Hg) and with severe heart failure. The initial management was done in ICU with proper inotropic support, anti-failure medication and broad spectrum antibiotic as the patient had temperature at that time.