The Pericardium
http://www.100md.com
《新英格兰医药杂志》
This book will go a long way toward redressing the widespread ignorance of the clinical and functional significance of the pericardium. The author, a master physiologist-cum-clinician in the mold of Louis Katz and William Dock, has produced a treasure trove of facts and personal insights, with many historical excursions and interpolations, to illuminate the state of the art and the state of the science. In keeping with his personal interests, the book is asymmetric: 62 pages (almost one fifth of the text) cover constrictive pericarditis; chapter 2, "Physiology," covers 54 pages; pulsus paradoxus gets 28 pages. Most of the text on common forms of acute pericarditis is highly concentrated at the end of the book; the author dismisses inclusive diagnostic lists as being of more interest to the epidemiologist than to the practitioner. Unfortunately, an overwhelming number of patients qualify for a diagnosis of acute pericarditis under "idiopathic" rubrics, which undoubtedly mask cases of uncommon causes that would not come to mind without the aid of checklists. (For example, pericarditis occurs in more than 30 individual entities in the vasculitis–connective-tissue disease group alone.)
Some of the most fascinating reading concerns the author's personal experiences in the experimental laboratory, where he elucidated conditions that permit pulsus paradoxus, and in a fascinating section, "Comparative Physiology," that describes his work on the pericardium of the elasmobranch fish, which, despite the presence of a pericardioperitoneal canal, can support tamponade. Equally interesting is the analysis of pericardial pressure as measured by the tip of a catheter, versus the nonuniform, pericardial contact force as measured by flat balloon, and the consequences of the former procedure for cardiac physiology, especially preload and true cardiac filling (i.e., distending, or transmural) pressures. Chapter 3 is an almost chatty practical guide to the identification, almost exclusively by echocardiography, of the presence and management of pericardial effusion. The 12-page section on techniques for imaging pericardial effusions is outstanding. Chapter 5, "Pericardiocentesis," comprises 21 pages that are packed with practical how-to information and illuminated by the author's personal insights; this chapter also describes pericardioscopy and balloon pericardiotomy. Elsewhere, devices for myocardial support are mentioned, principally the acorn jacket, which is designed to act like the pericardium — it is more compliant in the long axis than in the short axis — to support the myocardium during cardiac failure. There is also a concise discussion of the uses of pericardial tissue for the construction of bioprostheses.
The book has a few weaknesses, although certainly none in its factual material, its functional analyses, or its literary standards. The categorical title, The Pericardium, seems to promise comprehensive, if not encyclopedic, coverage. (The author may know that certain panjandrums of cardiology inveigh against "encyclopedic" inclusiveness.) Yet, except for fluid components, there is surprisingly little mention of the rich microphysiology of the pericardium. It is a veritable biochemical factory integrated with a complex autonomic-nerve supply, and this makes it particularly strange to some of us that so many patients seem unharmed by pericardiectomy. Perhaps such patients are either not followed long enough or not followed for the critical information. The index of the book is relatively anemic, with some topics not included even though they are well covered in the text, and a few topics, such as Dressler's syndrome, are indexed to the wrong pages.
These drawbacks, even the near-absence of the subject of pericardial microphysiology, pale beside the excellence of the areas that are covered and the particular asset of this text: the author writes so well that one wishes the book were longer and included subjects that have been omitted or only lightly touched on. For example, one cannot improve on Shabetai's description of the pericardium as "beautifully designed for the normal heart and [for] cop[ing] nicely with early stages of chronic heart failure. In severe or acute heart failure, the pericardium is an obstacle to maintaining a normal or compensated hemodynamic status." The high standard of narration, as expected of a Briton (Shabetai is from Manchester), makes almost every page a delightful read. Many physicians, particularly cardiologists and physiologists, who pick up the book for spot reading are sure to acquire one or more copies. The Pericardium would make a treasured gift for a favorite colleague.
David H. Spodick, M.D., D.Sc.
University of Massachusetts Medical School
Worcester, MA 01655
spodickd@ummhc.org((Developments in Cardiova)
Some of the most fascinating reading concerns the author's personal experiences in the experimental laboratory, where he elucidated conditions that permit pulsus paradoxus, and in a fascinating section, "Comparative Physiology," that describes his work on the pericardium of the elasmobranch fish, which, despite the presence of a pericardioperitoneal canal, can support tamponade. Equally interesting is the analysis of pericardial pressure as measured by the tip of a catheter, versus the nonuniform, pericardial contact force as measured by flat balloon, and the consequences of the former procedure for cardiac physiology, especially preload and true cardiac filling (i.e., distending, or transmural) pressures. Chapter 3 is an almost chatty practical guide to the identification, almost exclusively by echocardiography, of the presence and management of pericardial effusion. The 12-page section on techniques for imaging pericardial effusions is outstanding. Chapter 5, "Pericardiocentesis," comprises 21 pages that are packed with practical how-to information and illuminated by the author's personal insights; this chapter also describes pericardioscopy and balloon pericardiotomy. Elsewhere, devices for myocardial support are mentioned, principally the acorn jacket, which is designed to act like the pericardium — it is more compliant in the long axis than in the short axis — to support the myocardium during cardiac failure. There is also a concise discussion of the uses of pericardial tissue for the construction of bioprostheses.
The book has a few weaknesses, although certainly none in its factual material, its functional analyses, or its literary standards. The categorical title, The Pericardium, seems to promise comprehensive, if not encyclopedic, coverage. (The author may know that certain panjandrums of cardiology inveigh against "encyclopedic" inclusiveness.) Yet, except for fluid components, there is surprisingly little mention of the rich microphysiology of the pericardium. It is a veritable biochemical factory integrated with a complex autonomic-nerve supply, and this makes it particularly strange to some of us that so many patients seem unharmed by pericardiectomy. Perhaps such patients are either not followed long enough or not followed for the critical information. The index of the book is relatively anemic, with some topics not included even though they are well covered in the text, and a few topics, such as Dressler's syndrome, are indexed to the wrong pages.
These drawbacks, even the near-absence of the subject of pericardial microphysiology, pale beside the excellence of the areas that are covered and the particular asset of this text: the author writes so well that one wishes the book were longer and included subjects that have been omitted or only lightly touched on. For example, one cannot improve on Shabetai's description of the pericardium as "beautifully designed for the normal heart and [for] cop[ing] nicely with early stages of chronic heart failure. In severe or acute heart failure, the pericardium is an obstacle to maintaining a normal or compensated hemodynamic status." The high standard of narration, as expected of a Briton (Shabetai is from Manchester), makes almost every page a delightful read. Many physicians, particularly cardiologists and physiologists, who pick up the book for spot reading are sure to acquire one or more copies. The Pericardium would make a treasured gift for a favorite colleague.
David H. Spodick, M.D., D.Sc.
University of Massachusetts Medical School
Worcester, MA 01655
spodickd@ummhc.org((Developments in Cardiova)