Ventricular perforation is a rare complication during a high-risk percutaneous coronary intervention (PCI) when supported by Impella® (Abiomed). However, instrumentation of the left ventricle several days after transmural infarct potentially increases susceptibility for perforation. While a patient is on Impella support, physicians should review ventriculograms carefully to detect perforation and should consider the presence of a decompressed ventricle, the absence of normal systolic pressure and the movement of contrast from the ventricle into the aorta bypassing the left ventricular ejection. Immediate removal of the Impella if a perforation occurs must be avoided. Retrieving the device would risk a catastrophic bleed, while alternative repair techniques are available. Here, we describe a patient with a left ventricle perforation that occurred during a high-risk PCI supported by an Impella device.