| Summary: | Cardiac surgery involves use of cardiopulmonary bypass which usually requires a circulatory circuit containing numerous cannulae and tubings draining from major vessels (like superior and inferior vena cavae) and returning it back to the systemic circulation (via the aorta, femoral artery, axillary artery etc). Establishment of this circuit not only requires good surgical skills for technical procedures but also requires stringent vigilance and awareness about the working of these disposable items. Surgeons concentrating in the technical aspect might miss out on the minor manufacturing defects in these disposable items and anesthesiologist as well as perfusionist can contribute in this aspect by including systematic precheck of these items to avoid complications in future. In this case report, we would like to discuss a simple case of mitral valve replacement where during aortic decannulation the metallic tip got dislodged and thus got migrated to the abdominal aorta. This is a rare complication which none of us were expecting. By prechecking the various components of the cardiopulmonary bypass circuit, this complication was expected to be avoided.
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