Carol A. Hirshman, M.D., Editor
Transesophageal Echocardiography, Edited by William K. Freeman, M.D., James B. Seward, M.D., Bijoy K. Khandheria, M.D., A. Jamil Tajik, M.D. Boston, Little, Brown and Company, 1994. Pages: 599. Price:$185.00.
Transesophageal echocardiography (TEE) is becoming a standard-of-care monitor for open heart surgery, particularly for repair of the mitral valve. Selected closed cardiac cases, such as the coronary artery bypass patient with postinfarct angina and left bundle branch block, also may benefit. TEE may detect myocardial ischemia when the electrocardiogram is unhelpful or locate an intracardiac thrombus before the surgeon lifts the heart. Anesthesiologists will be expected to exhibit increasing levels of proficiency with TEE interpretation or yield the head of the table to cardiologists. Transesophageal Echocardiography, a comprehensive reference authored mostly by cardiologists, will be appreciated best by highly experienced echocardiographers.
The first chapters briefly review the history of TEE and offer an example for organization of the TEE laboratory and the requisite training of personnel. Beautifully prepared cadaveric specimens display basic cardiac anatomic structures in comparison with echographic images in the same plane of section. Specific advantages of biplane and omniplane examination are presented in contrast to the widely available and less expensive single-plane instrument. Seward's chapter on “Limitations and Pitfalls” of TEE ranks as one of very few self-contained discussions on the subject in texts devoted to TEE.
The core of the text includes sections on semiquantitative evaluation of ventricular function, regional assessment of ischemia, chronic valvular abnormalities, vegetations, and prosthetic valves. Although primarily directed to cardiologists who evaluate patients outside the operating room, the methods and conclusions will be appreciated by anesthesiologists who use echocardiography to guide intraoperative management. An excellent illustrated differential diagnosis of intracardiac thrombus and other mass lesions is presented in juxtaposition with a similarly thorough review of cardiac embolic sources. A well written but brief chapter on congenital heart disease could be developed into a complete text on the subject. Examination of the thoracic aorta is discussed in a separate chapter with appropriate discussion of the limited visualization of the ascending aortic segment.
Several specialty chapters are of particular interest to anesthesiologists. The chapter on intraoperative TEE presents criteria for a variety of intraoperative decisions with special emphasis on repair of the mitral valve. A systematic approach to the heart with residual disease being prepared for separation from cardiopulmonary bypass, however, was not included. A chapter on TEE in critically ill patients is case-oriented, with examples ranging from postoperative coronary revascularization with tamponade to evaluation of donors for cardiac transplant. The final chapter discusses three-dimensional reconstruction echocardiography without burdensome mathematics, although the importance of this methodology to cases such as cardiomyoplasty was left to the reader.
Transesophageal Echocardiography may be recommended as a comprehensive reference for anesthesiologists experienced with echocardiography, although the intended audience appears to be cardiologists working primarily outside the operating room. The text is less helpful in defining the important role of TEE monitoring when evaluating relative severity of multiple lesions in the setting of ongoing intraoperative insults or separating a patient from cardiopulmonary bypass. Anesthesiologists working with cardiology departments can use this text or its references when developing basic standards of care or beginning institutional TEE programs.
Lex Schultheis, M.D., Ph.D.; Assistant Professor; Department of Anesthesiology; The Johns Hopkins Medical Institutions; Tower 711; 600 North Wolfe Street; Baltimore, Maryland 21287.
