A 47-year-old female with RHD presented with complaints of dyspnoea on exertion (Class III) for 7 days. On presentation, the patient was hypoxic with SpO2 of 85% at room air and a respiratory rate of 22 breaths/min. Oxygen supplementation showed no clinical improvement. Physical examination showed clubbing and cyanosis, suspecting right to left shunting of blood. The first heart sound was loud; the pulmonary component of the second heart sound was accentuated. There was a mid-diastolic murmur at the apex with pre-systolic accentuation. Chest X-ray showed diffuse opacification in the left lower lobe of the lung with mild para-hilar congestion (). Echocardiography was done, which showed thickened mitral valve and severe mitral stenosis [mitral valve area (MVA) was 1.1 cm2 by 2D planimetry] with mild mitral regurgitation. The left atrium was dilated (size = 54 × 70 mm) with indexed left atrial volume of 105.72 mL/m2 and moderate tricuspid regurgitation with mild pulmonary artery hypertension (right ventricular systolic pressure = 39 mmHg) was present. Computed tomography (CT) pulmonary angiography was done, which revealed multiple PAVMs in the left lower lobe of the lung, involving the left lower lobe pulmonary artery ( and ). A complex intervention was planned consisting of balloon mitral valvuloplasty (BMV) and transcatheter embolotherapy of AVM by vascular plug. During the pre-operative cardiac catheterization, the basal mean pulmonary artery pressure was 18 mmHg, central aortic pressure was 101/82 mmHg (mean of 78 mmHg), and transmitral gradient (TMG) was 18 mmHg. The patient underwent BMV using 26 mm Inoue balloon (). The procedure was successful with MVA improving to 1.9 cm2, and TMG was 2 mmHg. The patient had one episode of transient ischaemic attack (TIA) immediately after the procedure. The patient recovered from TIA within 30 min with normal CT brain imaging. Hence, the embolization of AVM was planned as a staged procedure after 1 month. The patient was re-admitted after 1 month for the staged procedure. Pulmonary angiogram done via transfemoral vein access showed large and tortuous feeding artery (diameter = 14 mm) from the left lower branch of the pulmonary artery draining into the left lower pulmonary vein (). The fistula was entered with 5F Judkins right coronary artery catheter and 0.035 Terumo guidewire. An 8F long sheath was placed in the fistula over an Amplatz 0.035 super stiff wire. A 20 mm (30–50% larger than target vessel diameter) Amplatzer™ Vascular Plug II was selected as it had nitinol wire mesh ensuring rapid embolization and good on-table occlusion. The device was deployed in the fistula at the level of the left lower pulmonary artery branching under angiographic guidance (). Post-occlusion angiogram showed no significant feeding vessel draining to the left atrium. The basal oxygen saturation in the arterial blood gas improved from 87% to 98%. Post-intervention chest X-ray showed vascular plug in place with the clearing of lung opacification in the left lower zone (). The post-intervention course was uneventful. On short-term follow-up, the patient remained well and her oxygen saturation was 98% on room air.