This case involves a child who was born with hypospadia and a congenital heart defect, which required the replacement of a cardiac conduit. The conduit was from a cadaver donor and the parents were told that it would have to be replaced in eighteen years. The child had a perfectly normal, healthy, and active life up to the age of twenty-one. The physicians on this case chose not to replace the conduit until the patient reached twenty-one years of age. By that time, the conduit had developed significant scar tissue and fused to the chest wall. During surgery, the chest was opened, and the conduit immediately ripped away from the chest wall causing a massive intraoperative bleed. The patient suffered a prolonged period of hypotension along with several seizures. As a result, the patient passed away shortly after the operation and the cause of death was attributed to cardiac arrest.