To the Editor:—

Being from an institution that has experience in port-access heart surgery, I would like to make a few comments regarding a recent article in Anesthesiology. 1 

Dr. Chaney et al.  1are to be congratulated for their efforts to provide controlled data regarding the advantages and disadvantages of port-access cardiac surgery. Most of the Discussion section of their article dealt with the longer procedure times, greater technical complexity, uncertain benefits, and potential new morbidity related to port-access versus  standard operation.

As a matter of perspective, the article of Chaney et al.  1must be interpreted with caution. The results presented are clearly an early experience with port-access at one institution. Recent data from 738 patients undergoing port-access valve surgery at 27 institutions showed that operative times improve with experience even after 200 cases. 2As the authors admit, their reported initial experience with 46 patients was characterized by the lack of comfort of surgeons, anesthesiologists, and perfusionists that normally would accompany the adoption of new technology. After 400 port-access cases at Duke University, port-access procedures have become sufficiently streamlined that all anesthesia staff, cardiac operating room nursing staff, and perfusionists are quite comfortable with port-access techniques. More complex technologies of fluoroscopy, percutaneous pulmonary artery venting, percutaneous coronary sinus catheters, and centrifugal venous assist have been minimized.

It may be useful to remember the early days of laparoscopic cholecystectomy when similar concerns of increased operating room time, increased complexity, and uncertain outcome caused resistance among physicians for several years. Ultimately, streamlined technology and overwhelming patient demand have made laparoscopic cholecystectomy, but not necessarily other laparoscopic surgeries, dominant procedures today.

The ultimate role for port access will be decided not only by future controlled studies examining more mature technologies, but also by the patients.

*Duke University Medical Center, Durham, North Carolina.

Chaney MA, Durazo-Arvizu RA, Fluder EM, Sawicki KJ, Nikolov MP, Blakeman BP, Bakhos M: Port-access minimally invasive cardiac surgery increases surgical complexity, increases operating room time, and facilitates early postoperative hospital discharge. A nesthesiology 2000; 92: 1637–45
Glower DD, Siegel LC, Galloway AC, Ribakove G, Grossi E, Robinson N, Ryan WH, Colvin S, Shemin R: Predictors of operative time in multicenter port-access valve registry: Institutional differences in learning. Heart Surgery Forum 2001; (in press)