Patient History: DM-II, HTN since 5 yrs.Medical complaints: exertional Dyspnea for 1 monthK/C/O CRF- S. Creatinine-2.5mg%, ECG- LBBBDiagnosis: Bicuspid Aortic Valve, small annulus, calcified severe aortic stenosis

CT S/O RISK FACTORS TO CONSIDER—

ValveCrossing and Pre-Dilatation: The native valve was crossed using an ST wire overan AL1 support catheter. Prediction: Balloon Dilatation was performed using an18x40 mm balloon. CatastrophicComplication: The patient suffered a Cardiac Arrest as the new valve crossedthe annulus.EmergencyManagement: The operator immediately prioritised valve deployment, which wassuccessfully positioned and implanted.CauseIdentified: Post-deployment Echocardiography (ECHO) revealed a PericardialEffusion Resuscitation:CPR and repeated Cardioversion for recurrent Ventricular Fibrillation (VF) wererequired and continued for 10 minutes until spontaneous rhythm was restored.SurgicalIntervention: The patient was urgently taken to the Operating Theatre (OT) forExploration.SurgicalFinding: Right Atrial (RA) Appendage Perforation was identified as the sourceof bleeding. This is a known, though rare, complication often associated with the manipulation of the stiff guide wire or temporary pacing wire.TAVI ValveIntegrity: No Annular Leak was observed, confirming the new Myval THV waswell-seated and functional.Recovery: Thepatient was maintained on a ventilator overnight, successfully extubated thenext morning, and discharged after 5 days, indicating a full recovery from theacute complication.

Focus on Technique: Emphasises the need for Gentle Handling of wires and catheters within the delicate cardiac structures, especially the Right Atrium (RA) and Right Ventricle (RV).Risk Acknowledgement: Highlights that Rashness/Overconfidence can lead to potentially Lethal Perforations.Team Readiness: This case demonstrates CPR, cardioversion and immediate availability of Cardiothoracic Surgery for emergency bailout (Heart Team concept).