A 60-year-old lady with a past history of rheumatic mitral stenosis (MS), percutaneous valvuloplasty and persistent atrial fibrillation represented with heart failure. Cardiac ECHO confirmed severe MS, moderate tricuspid and aortic valve regurgitation and pulmonary hypertension. She underwent mitral and aortic valve replacements, a tricuspid valve repair and left atrial appendage clip. She developed a LV wall rupture and underwent repair of defect. Cardiogenic shock persisted despite IABP counter-pulsation and escalating inotropic support. Central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and 9 days later, a percutaneous Protek Duo right ventricular assist device (RVAD) for RV failure afforded a successful outcome.