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Reviews of Educational Material  |   November 2008
Anesthesia for Cardiac Surgery, 3rd Edition.
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  • Mayo Clinic, Rochester, Minnesota.
Article Information
Reviews of Educational Material / Cardiovascular Anesthesia
Reviews of Educational Material   |   November 2008
Anesthesia for Cardiac Surgery, 3rd Edition.
Anesthesiology 11 2008, Vol.109, 938-939. doi:10.1097/ALN.0b013e3181895dbb
Anesthesiology 11 2008, Vol.109, 938-939. doi:10.1097/ALN.0b013e3181895dbb
Anesthesia for Cardiac Surgery, 3rd Edition.  By James A. DiNardo, M.D., and David A. Zvara, M.D. Malden, Massachusetts, Blackwell, 2008. Pages: 463. Price: $174.95.
Nearly 10 yr ago, I read Anesthesia for Cardiac Surgery  , 2nd Edition. At that time, Dr. DiNardo’s text was recommended by many of the faculty and residents at our institution as a readable, informative text. Therefore, I was pleased to be asked to review the newer, updated version of this popular book. In the third edition, I found both familiarity and change as well as improvement and, unfortunately, some disappointment.
In the preface, authors DiNardo and Zvara describe their desire to create a cardiac anesthesia text that fills a perceived niche between large, definitive textbooks and smaller, outline-based handbooks. The third edition, like the second edition, meets this goal admirably. With its organized and well-written text, this book can easily be read cover to cover by a resident during the course of a 1- or 2-month rotation. Anesthesiologists in busy practices would also find this easy-to-read text to be a useful reference and concise review of current concepts in cardiac anesthesia.
The updates found in the third edition are extensive and quite apparent to those who have read the second edition. For example, the chapter devoted to mechanical assist devices contains a comprehensive review of the function and design of many of the newer devices, including axial flow pumps such as the Jarvik 2000 (Jarvik Heart, Inc., New York, NY) and the HeartMate II (Thoratec, Pleasanton, CA). Similarly, the chapter discussing valvular heart disease includes a brief description of some percutaneous approaches to valve repair. A table from the 2006 American College of Cardiology–American Heart Association task force guidelines for the management of valvular heart disease has also been included.
The organization of the third edition remains largely unchanged compared with the previous edition. In fact, although this new edition contains almost 50 more pages than the previous version, the number of chapters (13) remains the same. While some topics have been combined or slightly reorganized, readers of this newest edition will still find chapters devoted to preoperative evaluation, monitoring, cardiopulmonary bypass, myocardial preservation, and mechanical assist devices along with chapters detailing the anesthetic management of surgery for coronary artery disease, valvular heart disease, congenital heart disease, pericardial disease, and diseases of the thoracic aorta. This book clearly focuses on preoperative evaluation and intraoperative management of cardiac surgical patients. Those seeking information on postoperative care of cardiac surgical patients should look elsewhere. Similarly, those interested in a review of dysrhythmias or pacing will be disappointed.
Some differences between the second and third editions become apparent on the title page and continue throughout the book. Lead author DiNardo has been joined by coauthor Zvara, who replaces the two contributing authors of the second edition. In addition, the publisher has changed. Readers will note that the text of each chapter is no longer specifically referenced in the new edition. In the second edition, as many as 285 references were listed at the end of a chapter. The third edition drops specific citations in the text in favor of a short list of “suggested readings” (typically five to eight) at the conclusion of each chapter. In my opinion, the substitution of hundreds of specific references in favor of a few “suggested readings” does not serve the reader, though it certainly does make writing the book considerably easier. Furthermore, the few color echocardiographic images that were present in the second edition have been replaced entirely by black-and-white figures in the third edition.
Many of the strengths of the second edition are present in the third edition as well. Preoperative cardiac testing modalities, including echocardiography, nuclear techniques and angiography, are particularly well covered. Also, the entire text maintains a strong focus on cardiovascular physiology, providing a nice framework and rationale for the anesthetic management strategies that are presented. Ventricular pressure–volume loops are plentiful as are simplified diagrams of congenital lesions that include expected flows and saturations at various locations within the circulation.
Overall, the treatment of congenital heart disease is quite comprehensive, perhaps reflecting the lead author’s employment at a children’s hospital. Occupying nearly 20% of the text, the chapter devoted to the anesthetic management of congenital heart disease is by far the longest in the book. In addition to detailing anesthetic management strategies, this chapter describes a large number of lesions, physiologic consequences, and approaches to surgical correction. Although the bias toward congenital heart disease may not be reflective of the distribution of cardiac surgical cases in many practice situations, the heterogeneity and complexity of congenital heart disease probably warrants this expanded coverage. Indeed, this lengthy chapter would serve as a nice reference for those who encounter congenital heart disease only occasionally.
While the efficient writing style, the strong physiologic basis of management strategies, and the clear organization of chapters have remained intact in the third edition, the actual production quality has diminished markedly since the previous edition was published. Frankly, the number of typographical and spelling errors in the new edition is astonishing. I actually considered the possibility that I had been given a publisher’s proof instead of a final copy. A quick trip to our library and the examination of two other copies of the book eliminated this possibility. The first error I encountered was on the title page, where Dr. DiNardo’s institutional affiliation is listed as “Children’s Hospital Bostan.” Other notable errors include two spellings of the name “Fogarty” (catheter) on page 281. Similarly, nitroglycerin is abbreviated as both “NTG” and “TNG” in the same paragraph on page 266. In general, the typographical and spelling errors are merely a nuisance. However, in several instances, the mistakes are potentially problematic. For example, the recommended dose of dexmedetomidine listed on page 114 is 0.1–0.7 mg/kg/min. This represents a 60,000-fold deviation from the recommended dose of 0.2–0.7 μg/kg/h. Other terms such as “retrograde cerebral cardioplegia” (found on page 304) clearly represent typographical errors yet could be confusing for trainees. The errors in proofreading and editing listed above represent only a fraction of those found in the book.
The book is also plagued by internal inconsistencies. For example, on page 37, the authors declare that a nonindexed aortic valve area of 0.5–0.8 cm2represents moderate stenosis, whereas an aortic valve area less than 0.5 cm2is indicative of severe stenosis. However, on page 79, an aortic valve area less than 0.8 cm2is equated with severe stenosis. Also, the authors report on page 121 that dobutamine has “balanced”β2and α1activity in the dose range of 5–20 μg/kg/min. Yet on page 153, dobutamine is declared to have “no α-adrenergic activity” in this dose range.
Another example of suboptimal editing is found in the unnecessary duplication of large figures. For example, Chapter 3 includes two large diagrams detailing the assessment of diastolic function by transesophageal echocardiography. Curiously, these same two diagrams, each consuming more than half a page, are duplicated in the very next chapter. Incidentally, the discussion regarding the assessment of diastolic function by transesophageal echocardiography, which occupies more than two pages, seems disproportionate when the reader realizes that the use of transesophageal echocardiography to determine ejection fraction and fractional shortening is only described in the legend of figure 4.12.
While some figures are duplicated unnecessarily, the quality of other figures is remarkably low. A number of the transesophageal echocardiography images are so dark that they cannot be interpreted. For example, figure 5.11 attempts to show the diastolic doming of a rheumatic anterior mitral leaflet. Because of the extremely dark reproduction of this image, the included arrow essentially points at black space. Again, this text contains no color images.
In summary, it is difficult to issue an overall recommendation regarding this book. On the one hand, the length, writing style, and readability are excellent. Similarly, the strong physiologic basis for management strategies and the highly current nature of the included material weigh significantly in its favor. The topics presented represent those likely to be encountered in any practice of cardiac anesthesia. On the other hand, I have never read a medical text that contains so many typographical and spelling errors. While most of these errors are simply bothersome, others generate misinformation. Internal inconsistencies and poor attention to figure reproduction further degrade the quality of the book. Ideally, the editors would carefully reread and correct the entire text and print it again. If this were to occur, I would recommend it wholeheartedly.
Mayo Clinic, Rochester, Minnesota.