Medical errors follow a well-established association with communication failure. Seemingly benign interventions such as central venous catheterization can have far reaching consequences. A 72-year-old male required reoperative mitral valve replacement surgery for culture negative endocarditis. Intraoperatively, a central venous catheter was placed without communication between the surgical and anesthesia teams. Despite a seemingly uneventful operative and post-operative course, prior to

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... e, the catheter was unable to be removed and necessitated surgical removal. Bidirectional communication during cardiovascular surgery is key to achieving optimum outcomes. Fortunately, it often requires many errors to lead to unnecessary morbidity, however sometimes it takes but one.