34 T . Takeichi et al .: J Extra Corpor Technol 2025 , 57 , 32 – 37
Table 1 . CPB management and outcomes including preoperative CPB plan . CPB .: Cardiopulmonary bypass ; Rt FA .: Right femoral artery ; Rt FV .: Right femoral vein ; CI .: Cardiac index ; mABP .: Mean arterial blood pressure ; ICU .: Intensive care unit .
CPB management and outcomes
Preoperative CPB plan Cannulation ( RtFA : 18Fr , Asc Ao : 14Fr , RtFV : 23 / 25Fr ) Targeting CI : 2.0 – 2.6 L / min / m 2 , mABP : 60 – 70 mmHg Targetting rectal temperature : 26 ° C Systemic hyperkalemia combined with circulatory arrest Repeatedly circulation arrest : for up to 5 min Prevent oliguria management : 10 mL / h of continuous furosemide Targetting blood potassium level : 8.0 – 10.0 mEq / L Dialysis : Gravity drainage hemofiltration method
Operative CPB management CI : 2.4 L / min / m 2 mABP : 60 mmHg Nadir rectal temperature : 26 ° C Circulation arrest time : 25 min Cardiac arrest time : 90 min CPB time : 394 min
Postoperative outcomes
ICU stay : 3 day Ventilation time : 37 h Hospital stay : 16 days Major complications : None
Mean CI and mABP were 2.4 L / min / m 2 and 60 mmHg . Circulation arrest time , cardiac arrest time , and CPB time were 25 min , 90 min , and 394 min , respectively . Due to difficulty stopping bleeding , it became a long perfusion time . The duration of mechanical ventilation and length of stay in the intensive care unit ( ICU ) was 37 h and 3 days , respectively . The postoperative course was uneventful without cerebral infarction and he was discharged 16 days . Informed consent to report patient information and images was obtained .
Discussion
In recent years , a meta-analysis reported that minimally MICS for redo cases has many advantages over median sternotomy [ 1 ]. In our institution , we actively employ totally endoscopic MICS for redo cases , aiming to mitigate risks and optimize patient outcomes [ 9 ]. However , re-operative valve surgery is acknowledged to be more complex and has increased morbidity and mortality rates [ 10 ]. Moreover , patients with atherosclerotic disease such as intravascular thrombus or severe calcification are more likely to have postoperative cerebral infarction by using retrograde perfusion via the FA [ 5 , 11 ]. MICS through right minithoracotomy is often established CPB by commonly used femoral cannulation [ 2 , 3 ]. In patients with atherosclerotic and artheromic aorta , antegrade perfusion using axillary cannulation , or Asc Ao is performed to prevent postoperative cerebral complications [ 5 , 7 , 12 ].
Few studies have examined the clinical outcomes comparing combined with central cannulation and FA cannulation in MICS . Huang et al . reported that 96.9 % ( 317 / 327 ) of the patients undergoing femoral and axillary artery cannulation survived . In addition , their study indicated that incidences of permanent neurologic dysfunction , renal insufficiency , liver failure , and lower limb ischemia seldom occurred [ 4 ]. There are no perfusion strategies of MICS guidelines for atherosclerotic and artheromic aorta . In our institution , combined with ascending aorta or axillary artery and FA perfusion have selected if any of the following preoperative enhanced CT scan criteria were satisfied anywhere in the aorta or iliac arteries : thrombosis thickness > 4.0 mm , calcification present in the total circumference . In our institution , when inserting aorta cannulation , we employ the two-widow technique . A 14Fr central cannula pass through the cranial window , in two-window technique . Bleeding is controlled by intermittent snaring of the tourniquet [ 13 ]. This technique is safer than single central cannulation because we keep the femoral cannula as a backup during cannulation and de-cannulation . However , there is no evaluation of the mixing zone when antegrade and retrograde perfusion are combined during CPB . To understand the mixing zone in the case of the Asc Ao and FA perfusion , we conducted a simulation study using an arteriovenous circulation system [ 8 ]. This 3D model successfully reproduced near human hemodynamics . This 3D model simulator was developed as a percutaneous coronary intervention . In this simulation study , we have evaluated the mixing zone by inserting Asc and FA cannulation . Priming solutions for CPB used 25 % glycerol . Contrast agent ( Hexabrix , serial No 15HJ031 , Guerbet LLC ) infused with 10 mL of undiluted solution from the femoral cannula side . And , the study was performed without the aortic cross-clamping , like this case , reproduced under cardiac arrest ( Video 1 ). The simulation result illustrated the mixing zone when changing the cannulation size combination ’ s flow from 3.0 L / min to 5.0 L / min ( Figures 2 – 4 ). In this case , by using 14Fr in the Asc Ao and 18Fr in the FA , the mixing zone of 3.0 L / min ( FA side flow : 1.0 L / min , Asc Ao side flow : 2.0 L / min ) was recognized as being in the descending aorta , but the mixing zone of 4.0 L / min ( FA side flow : 1.4 L / min , Asc Ao side flow : 2.6 L / min ) and 5.0 L / min ( FA side flow : 1.6 L / min , Asc Ao side flow : 3.4 L / min ) approached near the aortic arch ( Figures 2a – 2c ). In this case , however , we did not measure the flow rate ascending the Asc Ao and FA , and from the result of the simulator , it is thought that the mixing zone was placed in the descending aorta as mean CI 2.0 L / min / m 2 ( 3.18 L / min ). For the