This document discusses strategies for minimal invasive cardiac surgery (MICS) at SGPGIMS, Lucknow. It describes different types of MICS procedures including epicardial and endocardial approaches. It discusses cannulation strategies like favoring central aortic cannulation over femoral and percutaneous femoral venous cannulation. It also describes techniques for direct aortic, SVC, and RA cannulation. Newer generation cannulae with improved designs for better flow and flexibility are highlighted. Different options for aortic cross-clamping like endoclamps and trans-thoracic clamps are mentioned. Pictures show setup and examples of different MICS procedures performed.

1. MINIMAL INVASIVE
CARDIAC SURGERY
Cannulation Strategies, Equipments
and Techniques
At SGPGIMS, Lucknow

2. Types of MICS
EPICARDIAL
•MIDCAB
ENDOCARDIAL
VALVE SURGERY
ASD CLOSURE
CARDIAC MASS RESECTION
CARPENTIER AND LOULMET CLASSIFICATION OF MICS

3. Instrument
Holder panel
Soft tissue
and or MICS
retractor
Surgeon
Position
1st
Assistant
Pump
Left groin cannulation
preferredSurgical
Tech.
Variations exist depending upon procedure,
body habitus and surgeon/anesthesia
experience.
MICS OPERATING ROOM
TEE
Anesthetist
Position

4. Current Cannulation Strategies
 Favours CENTRAL AORTIC rather than FEMORAL ARTERIAL
 Percutaneous Femoral Dual stage Venous Cannulation over
Neck Acess
 Transaxillary/ Transthoracic Clamping over Endo Clamp
resulting in low complication rates and a reliable
platform for a variety of MICS procedures

6. Direct Aortic Cannulation

7. Video – DIRECT AORTIC
CANNULATION

8. VENOUS CANNULATION STRATEGIES
• Percutenous Femoral Venous Cannulation
• Direct SVC Cannulation , percutenaous and
under vision
– Special way of holding SVC canula with a right angled forcep
practiced in our centre for SVC cannulation under vision.
– Advantage being no need of TEE for confirmation of position
– Return can be checked instantly and cannula position altered.
• Direct RA Cannulation (in Ministernotomy)
– Not widely mentioned but very sucessfullypracticed in our
centre

9. Peripheral Cannulation - SCHEMATIC
1. SHORT OBLIQUE INCISION
2. LOPP FEMORAL ARTERY (NOT VEIN)
3. PURSE STRING SUTURES
4. STAY SUTURE (OPTIONAL)
5. PROPOFOL ( AS A LUBRICANT) – OPTONAL
6. INCISE THE VEIN VERTICALLY – FOR BETTER REPAIR
Hegar reduces bleeding ,facilitates mild dilation
7. GRADUALLY ADVANCE THE CANULA WITH THE GUIDEWIRE FIXED WITH DRAPE SHEET (may withdraw
wire off and on for better slide and no kink)
8. TEE CONFIRMATION OF TIP AT RA
9. NOW CANULA CAREFULLY PPLACED AT SVC – RA JUNCTION
It will preferentially enter the RA appendage and roll. So guidewire readvanced with the nose
tip appropriately placed to facilitate entry into the SVC. Once in the SVC nose is advanced slowly
with TEE confirmation once position confirmed the the remains bit is done by advancing the
cannula over the stiletto itself to prevent injury at the junction

10. SVC pores
IVC pores
Right groin
Venous Access
2 STAGED PERIPHERAL VENOUS
CANULA
PERIPHERAL VENOUS
CANNULATION
Femoral Route

11. VIDEO – PERIPHERAL FEMORAL
CANNULATION

12. Distal Femoral Cannulation to maintain
peripheral limb perfusion during long hours of
clamp time

13. VIDEO - DIRECT SVC CANNULATION

14. VIDEO – DIRECT RA CANNULATION

15. Direct RA Venous Canula
Has malleable
stylet which aids in
direct atrial
cannulation and the
wire reinforcement
allows for a
drainage even with
vaccum assisted
drainage

16. SMOOTHER INLET TIP AND WIDE SIDE HOLES
BOTH FEMORAL AND JUGULAR ACCESS
WITH SAME CANULA
Easy to insert
Versatile
ADVANTAGES OF NEWER GENERATION CANNULAE

17. Newer Generation Canulae – performance
upgrades
• Shorter clamp site eases tubing management
• New radiopaque suture ring
• Thin-wall design promotes maximum flow rates
• Flexible and kink resistant.
• Stainless steel wire-winding and reinforced walls

19. Triple staged Canula
These Cannulae have 3
ports which accounts for
better drainage and
lower pressure drop
across the canula
accounting for better
hemodynamics .

20. Chitwood De Bakey Aortic
Clamp
COSGROVE Flexible TransThoracic Aortic
Occlusion Clamp
Endoclamp
AORTIC CROSS CLAMP
STRATEGIES

21. Our Spectrum
MICS MVR---- MICS AVR -----MICS ASD -----MICS CABG
ENDOCARDIAL EPICARDIAL

22. MICS MVR
• PICS WITH YOU SIR

23. MICS AVR

24. MICS ASD
• Edited pic with you sir

25. MICS CABG
MICS Theatre Set Up Harvesting LIMA using special LIMA Harvested
retractor
© Dr Lalit Kapoor

26. On 2nd POD