European Journal of Echocardiography Advance Access originally published online on February 7, 2008
European Journal of Echocardiography 2008 9(3):321-322; doi:10.1093/ejechocard/jen038
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Reply to the letter to the editor by F. A. Flachskampf et al. Determination of stenotic mitral valve area: new, old, and gold standards
Leopoldo Perez de Isla
Instituto Cardiovascular Hospital Clinico San Carlos Plaza de Cristo Rey s/n
Madrid 28040
Spain
Tel: +34 609 084225
Fax: +34 913 303290
E-mail address: leopisla{at}hotmail.com
We completely agree with the comments of Dr Flachskampf and Dr Klinghammer. In fact, as we concluded in the work ‘We should keep in mind the fact that 3D-echo planimetry may be a better reference method than the Gorlin method to assess the severity of rheumatic mitral stenosis’.1 Thus, we did not want to definitively establish 3D-echo as the new and free-of-pitfalls reference method for mitral valve area assessment.2,3 One aim of our work was to show that there is no method, even those ones considered as the ‘gold-standard’, free from limitations. In an intention to demonstrate this fact, we sought to obtain a combined reference method: working in this way, we tried to compensate and balance the limitations and pitfalls of each method with the limitations and pitfalls of the others. But, in agreement with Dr Flachskampf and Dr Klinghammer, the main limitation of this combined method is the lack of validation against a validated and objective reference method. Nevertheless, as said, every validation would not be free from other limitations. 2D-echo methods, invasive Gorlin's method, and even visual direct valve area assessment are not free from pitfalls.4,5 Thus, we would be comparing a method with limitations against other method with other limitations.
In summary, our intention was not to create a new and perfect gold-standard. Our aim was to show that every method has its inherent limitations, including the Gorlin's method. 3D-echo is a very useful clinical tool, even when it is compared with a combination of different methods. And obviously, one of the main advantages of 3D-echo is its non-invasive nature, far from the invasive Gorlin's method and extremely complicated to assess visual direct valve area measurement.
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- Pérez de Isla L, Casanova C, Almería C, Rodrigo JL, Cordeiro P, Mataix L, et al. Which method should be the reference method to evaluate the severity of rheumatic mitral stenosis? Gorlin's method versus 3D-echo. Eur J Echocardiogr (2007) 8:470–3.[Abstract/Free Full Text]
- Zamorano J, Perez de Isla L, Sugeng L, Cordeiro P, Rodrigo JL, Almeria C, et al. Non-invasive assessment of mitral valve area during percutaneous balloon mitral valvuloplasty: role of real-time 3D echocardiography. Eur Heart J (2004) 25:2086–91.[Abstract/Free Full Text]
- Zamorano J, Cordeiro P, Sugeng L, Perez de Isla L, Weinert L, Macaya C, et al. Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. J Am Coll Cardiol (2004) 43:2091–6.[Abstract/Free Full Text]
- Gorlin R, Gorlin SG. Hydraulic formula for calculation of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. Am Heart J (1951) 41:1–12.[CrossRef][Web of Science][Medline]
- Faletra F, Pezzano A Jr, Fusco R, Mantero A, Corno R, Crivellaro W, et al. Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices. J Am Coll Cardiol (1996) 28:1190–7.[Abstract]
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