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A modified twin-hole aortic cannula fascilitating open heart surgery through a 5-cm lower mini sternotomy

An article from the e-journal of the ESC Council for Cardiology Practice

Open heart surgery through smaller incisions offer cosmetic benefits with lower morbidity. Minimal invasive incisions permit access to all cardiac areas, require specialised equipment and experience, and provide the patient with a comfortable outcome.

Mini sternotomy incisions offer traditional exposure and are useful for many procedures. Since 1998 in our institution, this incision is a routine procedure for selected pediatric cases in whom tissue elasticity provides good exposure. We prefer mini sternotomy rather than other alternative minimal access techniques. Right anterior thoracotomy, transverse inframammary skin incision with vertical sternotomy or bilateral anterior thoracotomy may also be beneficial. A 4–5 cm midline lower incision offers classical exposure of median sternotomy. This incision could easily preceed a full sternotomy in an emergency situation. There is no need for endoscopic instruments. Defibrillation, deairing and sternal closure can be made safely and in a usual manner.

Once the thymus is removed, a standard aortic cannula may be inserted just beneath the intact upper sternum. Aortic cannulation has to be as high on the ascending aorta as possible.

The unexpected problem during our initial cases was exceedingly high aortic line pressure during cardiopulmonary bypass. Repositioning of the cannula during the procedure is necessary. These interruptions seem to lengthen the cross-clamp time and confuse the surgeons’ concentration. Hyperangulation of the cannula tip towards the anterior wall of the ascending aorta due to atypical position of the aortic cannula is the reason for this problem. Femoral arterial cannulation may be an alternative, but it must be avoided in the pediatric age group.

To resolve the problem, we have modified a curved aortic cannula. A second hole, equal to the size of the original outflow, is drilled proximally with a dentist’s high-spin drill. Insertion of this cannula does not require any additional technique or experience. It offers permanent and stable acceptable line pressure despite atypical position of the aorta throughout the procedure either with pulsatile and non-pulsatile techniques.


Minimally invasive techniques, such as MIDCAB, Robotic Surgery etc, require high technology and experience. Methods which do not need any expensive equipment also allow the surgeon to reach all cardiac structures with ease. We think that our modification with using a standard device improves the surgeons’ ability to perform classic operations through a small incision without any additional cost.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


Hagl, C., Stock, U., Haverich, A., Steinhoff, G. (2001). Evaluation of Different Minimally Invasive Techniques in Pediatric Cardiac Surgery : Is a Full Sternotomy Always a Necessity?. Chest 119: 622-627

Notes to editor

Dr Kıvanç Metin, and Dr.Öztekin Oto  
Dokuz Eylül University School of Medicine
Department of Thoracic & Cardiovascular Surgery

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.