- Reapply tonsil clamp to proximal aortic adventitia and apply caudal traction to bring cannulation site into view - This also stabilizes the aorta for cannulation - Hold aortic cannula in left hand, diffuser tip in contact with the center of aortic cannulation site - Cannulation ritual: check blood pressure to make sure it is low enough for cannulation, check ACT, compare diffuser tip diameter to the width of a fifteen blade - Fifteen blade is held in right hand, edge facing away from surgeon, positioned to start aortotomy just a little to right of the center of the cannulation site. - Announce aortic cannulation to team - Insert Fifteen blade into aorta, push slightly away and withdraw - Nearly simultaneous insertion of cannula into aorta, surgeon holds into position until secured with tie - Assistant tightens left Rumel tourniquet, secures with Kelly clamp - Surgeon hands right Rumel tourniquet to assistant - Assistant tightens right Rumel tourniquet, secures with Kelly clamp - Surgeon passes Zero silk tie on a pass behind cannula and both Rumels - Surgeon holds Rumels behind the aortic cannula - Assistant ties Zero silk around cannula and Rumels - Tight enough to indent the red rubber Robinsons of the Rumels - Knot should be behind the cannula if possible to avoid interference with sutures during the case - Surgeon announces intention to de-air the aortic cannula - Assistant coordinates with surgeon to remove tubing clamp from the de-airing Y line, which is directed into bowl with cardiotomy sucker to drain blood. - Surgeon uses a tubing clamp to tap bubbles away from the wall of the cannula - Hold the cannula close to the aorta while tapping to minimize potential trauma to aorta - Surgeon instructs assistant to clamp de-airing line when cannula is cleared to satisfaction, then hands the second tubing clamp to assistant so two tubing clamps secure and weight the line at the same angle. - One folded blue towel beneath aortic cannula, on top of Rumels - Aortic cannula secured to fold of top drape with Kelly clamp - Halfway folded blue towel on top of entire arrangement