In a 42-year-old male patient who was scheduled to undergo minimally invasive direct coronary artery bypass (MIDCAB), left internal mammary artery (LIMA) was harvested with left anterior mini-thoracotomy in an appropriate position. A written informed consent was obtained from the patient. Anatomic landmarks were used to guide venipuncture and the Seldinger technique was applied to accomplish percutaneous cannulation of the femoral vein. During right femoral vein cannulation, hypotension and bradycardia developed. Once the pericardium was opened through thoracotomy, the pericardium was tense and hemorrhagic bleeding had occurred. Following femoral artery cannulation, operation was emergently converted to on-pump surgery. Emergency sternotomy was performed. Right atrium, vena cava superior and inferior, pulmonary artery and aorta were seemed to be clean; however, the left atrial appendage (LAA) was injured. Bicaval cannulation was applied. The right atrium was opened. It was observed that the cannula passed through patent foramen ovale (PFO) (Figure 1, Video 1) and pierced the LAA (Figure 2, Video 2). The left atrium was repaired and PFO was closed. The PFO was not noted on preoperative transthoracic echocardiography. Then, a three-vessel bypass was performed as planned. There were no additional complications after the operation. The patient was transferred to the intensive care unit. He was discharged without any further problems.

Figure 1: Patent foramen ovale indicated by black arrow as an intraoperative image.

Figure 2: Rupture of left atrial appendage indicated by black arrow.

Video 1. Intraoperative view of patent foramen ovale through which cannula passed.

Video 2. Intraoperative view of damaged left atrial appendage showing free wall rupture.

Cannulation techniques are an essential component of minimally invasive cardiac surgery, and different cannulation technologies are currently available for different types of minimally invasive operations.[1] Many surgeons prefer to use femoral arterial cannulation, when there is no severe aortoiliac illness. A minor risk of embolization, ipsilateral limb ischemia, and retrograde aortic dissection exists with femoral artery cannulation.[2] Venous drainage for cardiopulmonary bypass is carried out through the femoral vein during a minimally invasive cardiac surgery. Since it aligns more straightly with the inferior vena cava, the right femoral vein is preferred. Complications of femoral vein cannulations are rather uncommon and include seroma and infection. However, more serious complications such as right ventricular perforation have been also reported.[3] To ensure the most optimal possible drainage, transesophageal echocardiogram (TEE) should be utilized to place the cannula tip in vena cava.[4] In our daily practice, we do not use TEE during MIDCAB. This is an important point for the prevention of such complication as in our case. To the best of our knowledge, no such complication has been reported in the literature. Finally, physicians should be cautious about this condition.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Concept: M.B., K.S.; Design: M.B., K.S.; Data collection and processing: K.S, O.K.; Analysis or interpretation: A.D., D,M.; Literature search: A.D., O.K, D,M.; Writing: A.D., D.M.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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