Fatal cerebral air embolism during open heart surgery caused by lung parenchyma to left atrial communication.

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.