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Ann Thorac Surg 1999;67:864-865
© 1999 The Society of Thoracic Surgeons

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How To Do It

Innominate vein cannulation for venous drainage in minimally invasive aortic valve replacement

^a Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard University Medical School, Boston, Massachusetts, USA

Accepted for publication August 10, 1998.

Address reprint requests to Dr Couper, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115

	Abstract

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Minimally invasive aortic valve or aortic root replacement may be carried out through a mini-hemisternotomy. Venous cannulation of the right atrium may be difficult, at best, and obstruct the limited operative field. We have carried out cannulation of the innominate vein with 25F or 27F thin-walled femoral venous cannulae in 20 patients. Transesophageal echocardiographic guidance is invaluable in safely passing the guidewire and subsequently the cannula into the right atrium. This approach results in an unobtrusive method of complete intrathoracic cannulation through a mini-hemisternotomy with the risks of femoral cannulation.

	Introduction

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Recent expansion in the use of minimally invasive approaches for open heart operations has increasingly relied on femoral venous cannulation for cardiopulmonary bypass. This typically requires an additional groin incision. One of the "minimally invasive" approaches for aortic valve (AVR), aortic root, and even mitral valve replacement is the mini-hemisternotomy [1]. We began our experience with this approach using direct right atrial appendage cannulation but found this to be difficult to access and control with hemisternotomy limited to down to the second or third interspace. We describe our technique of cannulation of the right atrium through the left innominate vein near or at its junction with the superior vena cava (SVC). We believe this to be a safe and convenient method to carry out cardiopulmonary bypass through this incision without comprising of the critical portion of the operative field.

	Technique

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A limited superior hemisternotomy down to the level of the second or third intercostal space is performed (Fig 1A). Transverse division of the right hemisternum allows separation of the sternal halves and exposure of the underlying ascending aorta and aortic root. A 4-0 or 5-0 polypropylene purse string is placed in the anterior wall of the innominate vein at or near its junction with the SVC. A guidewire is passed through the venous purse string through the SVC and into the right atrium. Transesophageal echocardiography confirms wire placement and monitors passage of a 25F or 27F Medtronic BioMedicus femoral venous cannula over the guidewire into the SVC and atrium. We have used the standard 50-cm long cannula; however, only 10 to 15 cm of the cannula needs to be advanced within the vessel to position the end of the catheter in the midatrium (Fig 1B). The ascending aorta is cannulated as usual with a standard cannula. Cardiopulmonary bypass is commenced as usual. After discontinuation of bypass, routine decannulation is performed.

View larger version (155K): [in this window] [in a new window]   Fig 1. (A) Vertical and hemitransverse division of the sternum (dotted lines) to the second or third interspace. (B) Venous and aortic cannulae are brought out by the superior aspect of the wound. (C) The cannulae are covered by the aortic cross-clamp and do not interfere with exposure at the level of the aortotomy.

	Comment

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We have used this technique in 20 patients ranging in age from 32 to 84 years. In addition to routine AVR, the following procedures can be carried out through this approach: resection of a subaortic membrane, ascending aortic with hemiarch replacement for aneurysm, AVR and myomectomy, and AVR with root replacement. In the first patient, direct cannulation of the right atrial appendage was not possible due to severe hyperinflation of the lungs and downward displacement of the right atrium subsequent to emphysema. Because of this problem, we cannulated the innominate vein. In all patients, we have achieved our usual flow rates on cardiopulmonary bypass comparable to those achieved with conventional right atrial cannulation (Table 1). Conversion to full sternotomy was required in 2 patients. In our ninth patient, attempted blind cannulation of the coronary sinus with a retrograde cardioplegia catheter (rigid stylet) resulted in a perforation of the coronary sinus near its os. With a growing experience using transesophageal echocardiographic-guided cannulation of the coronary sinus (ie, Heartport and mini-hemisternotomy AVR), we have improved our ability to safely place retrograde cardioplegic catheters. In our seventeenth case, passage of the venous cannula resulted in a posterior perforation of the SVC near the azygos vein origin, likely because of passage of the guidewire into the azygos vein. Use of the plastic vein introducer through the purse string helps direct the guidewire (Amplatz Extra Stiff-Curved Tip, Cook Inc, Bloomington, IN) straight down the SVC into the right atrium. Placement of the purse string near the innominate vein-to-SVC junction also straightens out thepath. Intraoperative transesophageal echocardiography is routinely used in these patients and aids in monitoring passage of the guidewire into the right atrium. The cannula is advanced over the guidewire only after confirmation of its presence in the right atrium.

	References

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1. Gundry S.R., Shattuck O.H., Sardari F.F., Bailey L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David H. Adams Lawrence H. Cohn Gregory S. Couper Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zlotnick, A. Y. Articles by Couper, G. S. Search for Related Content PubMed PubMed Citation Articles by Zlotnick, A. Y. Articles by Couper, G. S.