We present an unusual sequence of events leading to massive cerebral air embolism and death in a patient who underwent mitral valve re-replacement for failure of the previously inserted bioprosthetic valve. An iatrogenic communication was created inadvertently between the adherent lung parenchyma and the left atrium. It caused a massive influx of air from the lung into the left atrium and systemic circulation causing fatal cerebral embolization. Retroperfusion was not effective.

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