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Reply

Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905

The issue of cost is important and should always be a preoccupation when it does not interfere with our ability to care best for patients. We are not aware of a study on cost of AR evaluation and treatment. Thus, comments on increased cost are conjectural and our practice argues to the contrary. Indeed, the 10 to 15 min involved with AR quantitation may increase the operating cost of echocardiography, reducing net operative income somewhat, but there are other expenses to be considered. In our practice, after AR quantitation, other tests aiming at AR severity assessment, such as repeat transthoracic echocardiography, transesophageal echocardiography, or aortography, are exceptionally required. The cost of any such test far exceeds the additional effort involved in quantitative echocardiography, notwithstanding potential use of magnetic resonance imaging. As an example of such a phenomenon, the decline in additional testing after quantitative valvular disease assessment has been well documented in aortic stenosis (2).

Dr. Heidenreich also raises the question of averaging multiple measurements made on multiple different days. Making multiple measurements during the same examination is quite simple with the current equipment and part of our routine. We would be greatly concerned with the validity of a test based on a single-cycle measurement or eyeball assessment and would question the value of such a test, irrespective of its cost. Averaging measurements made on several consecutive days is an intriguing suggestion of Dr. Heidenreich. It may be of value with qualitative assessment, which is quite variable (3), but has not been part of the 2003 consensus guidelines on assessment of valve regurgitation (4).

We appreciate the advice of Dr. Heidenreich on future studies in AR, but currently the results of our prospective study are straightforward to apply. For predicting outcome (survival or cardiac events) after diagnosis, quantitative assessment of AR is superior to qualitative assessment. This superiority is not just statistical but also practical, defining a group of patients who are at high risk for complications and who would go undetected otherwise. Thus, for the echocardiographers proficient with these modern techniques, quantitative AR assessment should be part of a high-value clinical practice, will undoubtedly save society's monetary expenses by avoiding duplication of testing, and most importantly has proven its worth for patient management and long-term clinical outcome.

(Email: sarano.maurice{at}mayo.edu).

	REFERENCES

Top REFERENCES

 

1. Detaint D, Messika-Zeitoun D, Maalouf J, et al. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study J Am Coll Cardiol Img 2008;1:1-11.[Abstract/Free Full Text]
2. Roger VL, Tajik AJ, Reeder GS, et al. Effect of Doppler echocardiography on utilization of hemodynamic cardiac catheterization in the preoperative evaluation of aortic stenosis Mayo Clin Proc 1996;71:141-149.[Abstract]
3. Gottdiener JS, Panza JA, St John Sutton M, et al. Testing the test: the reliability of echocardiography in the sequential assessment of valvular regurgitation Am Heart J 2002;144:115-121.[CrossRef][Web of Science][Medline]
4. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography: a report from the Task Force on Valvular Regurgitation of the American Society of Echocardiography J Am Soc Echocardiogr 2003;16:777-802.[CrossRef][Web of Science][Medline]

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