J Card Surg. 2019;1–3. wileyonlinelibrary.com/journal/jocs © 2019 Wiley Periodicals, Inc. | 1 DOI: 10.1111/jocs.14222 CASE REPORT Massive air embolism resulting in ischemic stroke after left ventricular assist device implantation Aditya Bansal MD 1,2 | Faisal Akhtar MD, MPH 1 | Nathan P. Zwintscher MD 1 | Arnav Bansal 1 | Arjun Verma 1 | Vivek Sabharwal MD 2,3 1 Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana 2 The University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, Louisiana 3 Neurocritical Care, Ochsner Clinic Foundation, New Orleans, Louisiana Correspondence Aditya Bansal, MD, Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, 1514 Jefferson Hwy. New Orleans, LA 70121. Email: adbansal@ochsner.org Abstract We present the first case of ischemic stroke secondary to massive air embolus during implantation of a left ventricular assist device (LVAD). The patient experienced a suction event at the time of aortic cannula removal. Despite the use of all standard deairing techniques and flooding the operative field with continuous‐flow carbon dioxide, a significant amount of air was delivered into the ascending aorta through the LVAD pump. KEYWORDS air embolism, complications, heart failure, LVAD, MCS therapy, stroke 1 | INTRODUCTION Air embolism is a risk associated with open‐heart surgery. Mechan- ical circulatory support devices present additional challenges secondary to the potential for air to become entrapped within the device and the potential for air to be sucked in through system connections and suture lines, especially when the chest is open and exposed to surrounding air. Air has been shown to enter a left ventricular assist device (LVAD) via pleural air leaking into a left atrial inflow cannula. 1 left atrial appendage injury at the time of cardiectomy for heart transplant, 2 or cavitation air bubbles second- ary to outflow graft obstruction. 3 However, an LVAD‐associated air embolus has not been previously shown to cause an ischemic stroke. 2 | CLINICAL SUMMARY A 62‐year‐old male with ischemic cardiomyopathy was evaluated for advanced surgical options for heart failure. The multi- disciplinary heart failure team deemed the patient to be a good candidate for destination therapy LVAD implantation because of severely elevated pulmonary artery pressure and a transpulmon- ary gradient of 22 mm Hg. The patient’ s medical history was significant for type II diabetes mellitus, hypertension, coronary artery disease, arthritis, and hyperlipidemia. Preoperative carotid artery duplex scanning revealed normal nonobstructive carotid artery flow and antegrade flow in bilateral vertebral arteries. After successful induction of anesthesia, the patient was prepped and draped in the standard manner. Transesophageal echocar- diography (TEE) was performed to assess valvular structures and right ventricular function. After median sternotomy and systemic heparinization, the patient was placed on full cardiopulmonary bypass (CPB) with aortic arterial and right atrial venous cannulation. A HeartMate II (Abbott, Abbott Park, IL) LVAD was implanted using the standard “cut‐and‐sew” technique, utilizing multiple interrupted pledgeted stitches around the left ventricular apex. Continuous‐flow carbon dioxide at 4 L/min was used to flood the operative field to minimize the risk for air embolism. After implantation of the LVAD, the heart and LVAD were thoroughly deaired using the usual deairing steps—placing an aortic root vent in the ascending aorta and creating a deairing hole in the outflow graft—before separating the patient from CPB. The LVAD was connected to the power console and started at 6000 rpm. Once TEE confirmed deairing of the heart, the patient was completely separated from CPB. With volume This study was previously presented as a poster at the 2016 International Society of Heart and Lung Transplantation Annual Meeting in Washington, DC.