Central Cannulation in Atrial Septal Defect Closure Via a Transaxillary Approach

This video demonstrates central cannulation for surgical closure of a secundum atrial septal defect via a right transaxillary approach. The patient was positioned in a left lateral decubitus position with the right arm elevated to optimize exposure of the axillary region.

A limited incision was made in the fourth intercostal space along the midaxillary line, and the thoracic cavity was entered. The pericardium was opened anterior to the phrenic nerve and suspended using stay sutures to enhance visualization. Due to the restricted operative field, careful retraction and the use of long instruments were essential to adequately expose the ascending aorta and right atrium.

Central aortic cannulation was performed by placing a purse-string suture on the ascending aorta, followed by cannula insertion under direct vision. Particular attention was paid to alignment and control, given the limited angle of approach.

Venous drainage was established via bicaval cannulation. The superior and inferior venae cavae were dissected and cannulated using angled cannula. Exposure of the superior vena cava was challenging and required meticulous technique. Both cavae were snared to ensure effective venous return. After deairing, cardiopulmonary bypass was initiated, and adequate flows were confirmed. The right atrium was opened, and the atrial septal defect was visualized.

The defect was closed using a patch, ensuring complete closure without residual shunting. Following repair, the patient was weaned from cardiopulmonary bypass. Cannulae were removed, and careful hemostasis was achieved within the confined space. A chest drain was placed, and the incision was closed in layers.

This technique demonstrates that central cannulation can be safely performed through a transaxillary approach. It avoids femoral access while preserving the advantages of antegrade perfusion. With appropriate patient selection and surgical expertise, this method provides effective repair with excellent cosmetic outcomes.

This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.  

References

1. Kandakure PR, Batra M, Garre S, Banovath SN, Shaikh F, Pani K. Direct Cannulation in Minimally Invasive Cardiac Surgery with Limited Resources. Ann Thorac Surg. 2020 Feb;109(2):512-516

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