To the Editor:-One result of the recent increase in popularity of minimally invasive cardiac surgery is that anesthesiologists are increasingly being called on to directly assist in the surgical management of the patient by performing invasive interventional procedures such as placement of a coronary sinus (CS) catheter or pulmonary artery vent. In the August issue of Anesthesiology, Abramson and Giannoti report a case of unrecognized, iatrogenic perforation of the right ventricle while attempting to cannulate the CS during preparation for minimally invasive cardiac surgery. [1]Although the technical difficulty and morbidity associated with CS catheter placement are low when performed by experienced personnel, [2,3]patient care may be compromised when a single anesthetic provider is asked to perform interventional procedures while simultaneously being responsible for patient monitoring and the delivery of a safe anesthetic.

In our institution, the attending anesthesiologist identifies and maintains visualization of the CS with transesophageal echocardiography (TEE) while the cardiac anesthesia fellow manipulates the CS catheter. Simultaneously, a dedicated anesthesia resident is responsible for patient monitoring and anesthetic delivery. Although this may work well in an academic institution, we realize that this level of staffing is not practically feasible or profitable in most circumstances. We contend, however, that patient care may be compromised when a single anesthetic provider is called on to simultaneously perform TEE, cannulate the CS, and deliver anesthesia. Thus, the presence of a second dedicated anesthesia provider during the performance of such invasive interventional procedures may be necessary to ensure quality patient care. We wonder if the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists should consider this issue and formulate practice guidelines regarding patient care during the performance of interventional invasive procedures such as cannulation of the CS for minimally invasive cardiac surgery.

Wilfred R. Lewis, M.D.

Fellow in Cardiac Anesthesia

Charles D. Collard, M.D.

Instructor of Anesthesia; Department of Anesthesia; Brigham & Women's Hospital; Harvard Medical School; Boston, Massachusetts 02115;

(Accepted for publication December 7, 1998.)

Abramson DC, Giannoti AG: Perforation of the right ventricle with a coronary sinus catheter during preparation for minimally invasive cardiac surgery. Anesthesiology 1998; 89:519-21
Applebaum RM, Cutler WM, Bhardwaj N, Colvin SB, Galloway AC, Ribakove GH, Grossi EA, Schwartz DS, Anderson RV, Tunick PA, Kronzon I: Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery. Am J Cardiol 1998; 82:183-8
Plotkin IM, Collard CD, Aranki S, Rizzo RJ, Shernan SK: TEE-guided percutaneous coronary sinus cannulation during minimally invasive cardiac surgery. Ann Thorac Surg 1998; 66:2085-7