Traditionally, cardiac surgery has been practiced primarily through a median sternotomy; however, as instrumentation and experience continue to advance at exponential rates, the field of minimally invasive cardiac surgery (MICS) is rapidly expanding. When compared with a conventional sternotomy, alternative access offers patients the potential benefits of decreased infection risk, reduced transfusion requirements, decreased length of admission, quicker return to normal activity, and, perhaps most important for patients, improved cosmesis.^1–3

The smaller incisions used in MICS and the distance from the mediastinal structures can make traditional central cannulation challenging. Furthermore, with MICS using a very small operative field, moving additional instrumentation out of the field is ideal, and as such, alternative cannulation strategies are frequently employed. At our institution, we prefer arterial access via the femoral artery, with axillary and central cannulation strategies used if the femoral artery is not suitable for safe institution of cardiopulmonary bypass (CPB).^4,5 Venous cannulation is almost always performed via a femoral vein with or without an additional internal jugular (IJ) cannula. We hereby discuss our approach to cannulation for MICS operations.