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A healthy 50 year old woman was admitted to hospital with abdominal pain. Abdominal x ray revealed pneumoperitoneum and she was taken to the operating room with suspected perforation of the viscera. The duodenum was operated on because of the perforation with accompanying peritonitis, and the patient required dopamine for blood pressure support. The haemodynamic status was compatible with septic shock. Thoracic x ray during the following 48 hours showed progressive development of respiratory distress syndrome. Positive pressure ventilation was administrated. Fifty six hours after surgery, the patient became acutely cyanotic with decreased systolic arterial blood pressure and arterial oxygen saturation; a new loud systolic retrosternal murmur, that was not present before, had also developed. Transthoracic echocardiography using harmonic imaging showed normal left ventricular function and normal valvar function (AO, aortic valve). The right ventricle (RV) appeared slightly dilated but with normal function. Air bubbles were seen in left atrium (LA) and left ventricle (LV) during mechanical ventilation in the inspiratory phase (arrows, panel A). No air bubbles were seen during apnoea. There was no evidence of an atrial or ventricular septal defect, as indicated by the absence of abnormal colour Doppler flow and by the lack of contrast material seen in the left side of the heart after intravenous injection of agitated saline solution. This event was time limited (another study that did not show bubbles was performed, panel B) and the patient’s haemodynamic status improved within three minutes while tidal volume was reduced. The patient died three days after the event from refractory hypoxaemia and hypotension.