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Background: Severe tracheobronchomalacia significantly complicates the postoperative course of infants and children with congenital heart disease, tracheoesophageal fistula, and tracheal stenosis. We have found that traditional approaches, including aortopexy, have been inconsistent in preventing acute life threatening events (ALTEs). In order to directly support the anterior tracheal wall, we have adopted the use of direct anterior tracheal suspension (ATS)., Methods: Twenty-one children, median age 5 months (35 days to 11 years) and weight 5.0 (2.3 to 28.0) kg have undergone anterior tracheal suspension for severe tracheobronchomalacia through median sternotomy; 15 for inability to ventilate despite mechanical respiratory support, 3 for intermittent ALTEs without mechanical respiratory support, and 3 for recurrent respiratory admissions. Nine procedures were performed as isolated ATS and 12 procedures were combined with at least 1 of the following: repair of ventricular septal defect; vascular ring; atrioventricular canal; tracheal reconstruction or arterial-pexy. Level of respiratory support was graded at preoperative (preop), discharge, and follow-up, and respiratory clinical status was graded at preop and follow-up. Median follow-up was 30.0 months (2.0 to 57.0 months)., Results: There was no mortality. Both level of respiratory support and the clinical status improved at all time points studied compared with preoperative score (p < 0.001) after ATS. Whether ATS was performed in isolation or combined with other procedures did not impact these findings., Conclusions: Anterior tracheal suspension is feasible and appears effective in dramatically improving respiratory clinical status. Tracheal suspension is applicable to a wide range of anatomic variants. Additional study is needed to characterize long-term functional outcomes., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)