To the Editor:-We read with interest the case report of a perforation of the right ventricle with a coronary sinus catheter during preparation for a Port-Access [trade mark sign] minimally invasive cardiac surgery procedure. 
It is important for anesthesiologists to be aware of this possibility during the insertion of any catheter within the heart, particularly during Port-Access [trade mark sign] procedures, in which multiple catheters and cannulae are used. However, we would like to clarify several terms used and techniques described in this case report.
The authors refer to a “pulmonary artery stent.” Port-Access [trade mark sign] cases do not include the use of stents. Rather, the catheter placed in the pulmonary artery is a vent used to decompress the heart. At our institution, we have all but abandoned the use of the Heartport [registered sign] Endopulmonary Vent [trade mark sign] catheter because with adequate venous drainage, it does not seem to be necessary. Furthermore, it precludes the use of a thermodilution pulmonary artery catheter, which can be valuable in the management of these cases.
We have also reduced significantly the use of the Heartport [registered sign] Endocoronary Sinus [trade mark sign] catheter during mitral valve procedures because surgeons have developed a technique of placing a retrograde cardioplegia catheter from the surgical field, with the aid of transesophageal echocardiography (TEE). We have found this to be faster than the percutaneous transvenous approach and to reduce the need for fluoroscopy. It also possibly reduces the risk of perforation. During myocardial revascularization procedures, we have also reduced the use of the Heartport [registered sign] Endocoronary Sinus [trade mark sign] catheter, except in those cases with concomitant aortic regurgitation.
The authors placed the Heartport [registered sign] Endopulmonary Vent [trade mark sign] catheter before the Heartport [registered sign] Endocoronary Sinus [trade mark sign] catheter. We prefer to insert these catheters in the reverse order because coronary sinus catheterization and visualization with TEE and fluoroscopy may be easier when the right atrium is free of other catheters, avoiding multiple, possibly traumatic, attempts.
Finally, in the discussion of their case, the authors refer to “non-pump coronary revascularization.” The Heartport [registered sign] technique always uses extracorporeal circulation.
Rafael A. Ortega, M.D.
Associate Professor of Anesthesiology;firstname.lastname@example.org
J. Fredrik Hesselvik, M.D., Ph.D.
Associate Professor of Anesthesiology; Department of Anesthesiology; Boston University Medical Center; Boston, Massachusetts 02118
(Accepted for publication December 7, 1998.)