Endoscopic Minimally Invasive Beating-Heart Tricuspid Valve Surgery Without Jugular Vein Cannulation or Caval Snaring: Clinical Outcomes Using Novel Percutaneous Venous Cannulation

Background and Objectives: Endoscopic beating-heart tricuspid valve (TV) surgery is increasingly adopted in cardiac surgery due to its association with improved postoperative recovery. Conventional approaches require jugular vein cannulation to establish adequate bicaval venous drainage, and caval snaring is considered mandatory during beating-heart TV procedures to prevent intraoperative air lock. We report our single-center experience with a novel percutaneously placed venous cannula (Smart Cannula) that enables minimally invasive TV surgery without jugular cannulation or caval snaring. Materials and Methods: Between February 2025 and May 2026, 31 consecutive patients underwent endoscopic beating-heart TV surgery using the Smart Cannula system for venous drainage. The device is a stent-like cannula with distributed wall perforations allowing sufficient venous return while preventing air lock. Preoperative atrial fibrillation was present in 21 patients (68%). Six patients (19%) underwent isolated TV procedures; the remainder had concomitant procedures. Mean age was 68.2 ± 10.8 years; 16 patients (52%) were female. Two different cannula lengths were used: 680 mm (n = 15) and 730 mm (n = 16). Six patients (19%) had history of prior cardiac surgery. Results: All procedures were completed without intraoperative air lock. Two patients (6%) required intraoperative conversion to sternotomy. Mean cardiopulmonary bypass time was 163 ± 52 min. Seven patients (23%) underwent beating-heart procedures with no aortic cross-clamping; in 24 patients (77%), aortic cross-clamping was required for concomitant procedures (mean cross-clamp time 79 ± 28 min), with tricuspid repair completed on the reperfused beating heart. Re-exploration for bleeding occurred in two patients (6%). Median ICU stay was 5 days and median hospital stay was 10 days. New permanent pacemaker implantation was required in three patients (10%). Thirty-day mortality was 0%. Postoperative echocardiography at discharge demonstrated TR Grade 0 in 61%, mild TR in 32%, and moderate TR in 3% of patients. Conclusions: In this first and largest published series on endoscopic beating-heart TV surgery without caval snaring or jugular vein cannulation, we have shown that the process is feasible and safe, eliminating the need for jugular vein cannulation and caval snaring while maintaining no occurrence of intraoperative air lock. The device enables a simplified venous drainage strategy without compromising operative safety or early clinical outcomes.