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Review of: Comprehensive Textbook of Intraoperative Transesophageal Echocardiography. Savage & Aronson (Editors)


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Savage & Aronson:
Solid Base For Review

Comprehensive Textbook of Intraoperative Transesophageal Echocardiography
Robert M Savage & Solomon Aronson (Editors)
716 pages, Over 1000 full color illustrations and images.
Extensive bibliography, Chapter review questions (with answers).
Hardbound, 2004

One text cannot do it all, but this one comes close (Overview).

The book seems to have two goals: Clinical use of TEE in the cardiac operating room; and passing the "Echo Exam."

When it comes to echocardiography I am a tyro. Thus the review of this work is not from the perspective of an expert in the field, but from that of someone who is trying to use this book as intended: as a textbook in transesophageal echocardiography. It is an excellent text for this. Were it not for a curious omission, and for what I think an excessive number of errors (especially in one chapter) for a book of this importance and price, I would give it five stars.

Echocardiography is primarily a visual discipline, and this book is profusely, and for the most part well, illustrated. The publisher's web site claims "1,000 full-color echocardiograms" and I expect this is true.

The illustrations, for the most part, can only be called superb. But, reflecting of what I see as lack of editorial oversight, several chapters have illustrations which simply best illustrate that one cannot take Power-Point® slides and turn them into even barely acceptable book plates. Fortunately the chapters which took this approach are the most dispensable.

Sticking with lack of editorial cohesiveness for a moment, I personally found it disruptive that the text for multi-image figures in some chapters used the "A) … Text", whilst that in others used "Text … A)" formatting. Why yes, I am detail oriented, and, yes there are larger issues in the world: but there is no more reason for doing this than there would have been to have switched typefaces or fonts with each chapter.

In addition to the illustrations, each chapter has a well written, in-depth text, an extensive bibliography, and concludes with Echo Exam review questions. Truly the only subjects which I thought could have been better covered were the determination of IVRT and a more clear presentation of parachute mitral valve.

There are over a hundred contributing authors. This gives expert coverage in each area, but, inevitably, leads to duplication. Perhaps a bit too much duplication, especially of images. Truly, does the Cleveland Clinic have only one TEE frame of an Alfieri repair, or of the RUPV? The more you see, the more you see. Repeatedly viewing the same image simply does not help to broaden ones visual memory and range. Again, I think that more aggressive editing would have caught this, and would have presented the learner with an even wider range of images.

Leaving aside the very few, very short, fluff chapters, save for a single exception the chapters are of an optimal size to be studied in an evening. This is important, as it gives the student a sense of progress in a very complex subject which at times seems overwhelming. Concise, clear, small chapters also makes going back to review a particular point quite easy.

The exception is chapter 28 "Assessment in Mitral Valve Surgery" which, at 85 pages (excluding bibliography and questions), is simply too long. It could have, should have, been broken down into several separate chapters. It is notable that similar information on the lesser complexities of the aortic valve is presented in two comfortably sized chapters.

Also notable is the density of errors which appear in this oversized chapter. I do not know if the chapter editor was simply overwhelmed with the task, or if the chapter was turned in late. In any event, the errors are all of a nature that should have been caught and which do detract from the discussion of one of the most difficult and important areas in TEE.

Two examples will suffice. In table 28.2 the ME LAX MV views are mistakenly shown for the ME 2C MV (later correctly shown in Fig 28.31). This is simply an editorial mistake, as no knowledge of echocardiography is needed to see that the drawings are repeated. A more subtle error is found in Fig 28.70 where the derivation of a simplified ROA estimation drops the square of the radius from the equation. There are many others, many more than in the remaining chapters.

Yes, I do realize there will be mistakes in any text. I became painfully aware of this in the early 1980s when trying to learn i86 assembly language. Assembly language is the lowest level human readable programming language for a particular processor. All of the early texts had errors: fortunately no two had the same, so one could piece things together. This seems to be true of current echo texts as well.

I find learning echocardiography about as difficult as learning assembler, and, at my level, I do not recognize all of the errors in the texts. I expect that many other learners may be as confused as I by TEE's murky grey images overlaid with swirling bright colors. In such a complex field, I believe textbook editors should take special pains to insure accuracy.

All that aside, the MV assessment chapter (28) still has a wealth of well presented information. Indeed the single most valuable insight I gained from the book was on page 459 of this chapter. My epiphany was the realization that the mitral valve is oriented near vertically. Somehow I had missed this fact in all the reading, courses, dissections, videos, and actual echoes I have done. The "3D Imaging Plane View" illustrations on this page made the orientation obvious. For me this alone was truly worth the price of the book. Sadly, turning the page immediately brings one to the most egregious error in the work.

On the whole the book is tightly focused on developing the knowledge and skills to effectively use transesophageal echo in the cardiac operating room. I would have preferred a chapter on transthoracic echo to some of the surgical minutia and to the odd inclusion of a chapter on basic statistics. Though the latter is an exceptionally well written chapter, I was perplexed at its appearance in a book on TEE in the OR.

The twenty-nine page appendix also confounds me. Whilst a useful compendium of echocardiographic tables, the pages are perforated. Perhaps there are those who would rip out the pages in a two-hundred dollar book, but I am not among them. So, for me, it simply means I had to run tape along them to keep them from tearing loose on their own.

As to the book's suitability for preparation for the PTEeXAM I cannot actually say, as I am still trying to figure out if I am eligible to sit for the exam, and, if so, which certification I might be eligible for. No more whining about this confusion here, there is enough of that at any echo conference. However, given that the many of the authors of the exam are also authors of this book I expect that time spent with this book would be repaid.

What is surprisingly missing from this text is an accompanying video disk. Given the importance of moving pictures to understanding echo and the low cost and ease with which a disk can be included in a book, this is a curious omission indeed. Sidebotham's very excellent Practical Perioperative Transoesophageal Echocardiography does include such and I would strongly recommend purchasing that text in addition too, or, if cost is an issue, instead of, this more comprehensive and expensive text. The addition of videos, in my opinion, more than makes up for the lesser coverage in Sidebotham.

It is possible that a disk was to have been included, as, when I came to this Amazon page to write the review under "Editorial Reviews" I saw it stated "An enclosed CD-ROM includes full-color TEE videos and multiple-choice questions and answers for self-assesment [sic] and exam preparation."

I purchased my volume directly from a Lippincott sales table at the ASA, and it is possible that I simply got one without a disk. However, the Lippincott web site makes no mention of such a disk in their description of the book. My suspicion is that this is something that was dropped at the last minute. I did write Lippincott and have asked, but have not yet had a reply.

You cannot go wrong by purchasing this book (with or without the mystery disk) as it gives an extensive, clear, in-depth introduction to transesophageal echo in the operating room.

Sadly though, when studying echo, one is left with the sense of mastering the horse and buggy (2D echo) whilst knowing the motorcar (3D) is just around the corner.

Bonne Chance.

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