How I do it: transapical cannulation for acute type-A aortic dissection

Femoral artery cannulation with retrograde perfusion is the most common method but because of the risk of malperfusion of vital organs and atheroembolism related to it different sites such as the axillary artery, the innominate artery and the aortic arch are used. Cannulation of these sites is not without risks of atheroembolism, neurovascular complications and can be time consuming. Another yet to be popularised option is the transapical aortic cannulation (TAC) described in this article. TAC consists of the insertion of the arterial cannula through the apex of the left ventricle and the aortic valve to lie in the sinus of Valsalva. Trans-oesophageal guidance is necessary to ensure correct placement of the cannula.TAC is an excellent method of establishing cardiopulmonary bypass as it is quick, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of the true lumen.Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients diagnosed with acute type-A aortic dissection die within 48 hours of presentation. The principal aim of surgery in type-A aortic dissection is to prevent aortic rupture and further dissection into the aortic valve and coronary ostia.The most popular approach to establishing arterial return for cardiopulmonary bypass (CPB) in type-A aortic dissection is femoral cannulation with retrograde perfusion of the aorta. Although this technique has been used since 1950s, it is not without its problems. The retrograde perfusion of the aorta has a potential risk of cerebral embolisation of atheromatous debris and extension of the dissection flap. The technique may also result in intraoperative malperfusion of aortic branch vessels. The alternative sites for arterial cannulation which also allow antergrade perfusion of the aorta include the aortic arch, axillary artery and the innominate artery [1,2].However, these approaches are not strictly antegrade as