A hemodynamically stable neonate with transposition of the great arteries suddenly went into cardiac arrest during preparation for transport to the operating room. Emergency echocardiography during cardiac massage detected coronary air embolism as the presumed cause of arrest. After about 15 minutes of resuscitation, it was possible to establish return of spontaneous circulation. Since the most likely source of air was the neonate's peripheral venous line, we have introduced inline microfilters for all neonates and all patients with right-to-left shunt lesions and did not encounter proven air embolism thereafter.
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