INTRODUCTION: Femoral venous cannulation is widely used to establish cardiopulmonary bypass (CPB) during minimally invasive cardiac surgery (MICS). Although transesophageal echocardiography (TEE) is commonly used to guide cannula placement, cannula malposition can still occur, and preserved venous drainage may delay the recognition of cardiac injury. We report a rare case of right ventricular perforation caused by femoral venous cannulation during minimally invasive aortic valve replacement (AVR), emphasizing that adequate venous drainage does not exclude cannula malposition or cardiac perforation.

CASE PRESENTATION: A 79-year-old man with severe aortic stenosis underwent minimally invasive AVR via a right mini-thoracotomy. Venous drainage was established via the right femoral vein using a 25-Fr, 55-cm HLS venous cannula with 24 side holes (BE-PVL 2555; Maquet Cardiopulmonary, Rastatt, Germany) under transesophageal echocardiographic guidance. Vacuum-assisted venous drainage was used. The guidewire was advanced toward the superior vena cava, and the cannula tip was initially considered to be positioned within the right atrium. After CPB was initiated, venous drainage became insufficient. The cannula was advanced blindly by approximately 2 cm, after which venous return improved. The valve procedure was completed uneventfully; however, pericardial bleeding became evident during volume loading before weaning from CPB. Conversion to median sternotomy revealed that the cannula had perforated the anterior free wall of the right ventricle and protruded into the pericardial cavity. The injury was repaired with a pledgeted mattress suture, and the patient recovered without further complications.

CONCLUSIONS: Adequate venous drainage during CPB does not confirm correct femoral venous cannula positioning. When venous drainage is inadequate during MICS, blind advancement of the femoral venous cannula should be avoided, and cannula position should be reassessed using multiple modalities, including TEE and fluoroscopy, when available.