Case Presentation: We present a 20 year old gentleman in acute hypoxic and hypercapnic respiratory failure and cariogenic shock secondary to hemodynamically unstable hemoptysis requiring mechanical ventilation and vasopressor support with norepinephrine and vasopressin. He had history of pulmonary atresia with intact interventricular septum at birth post right ventricular outflow repair and 1.5 ventricular repair [...]