Annals of Pediatric Cardiology
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Table of Contents   
LETTER TO EDITOR  
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 314-315
A pediatric echocardiographic Z-score nomogram for a developing country: Indian pediatric echocardiography Study – The Z-score


Department of Paediatrics, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq

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Date of Web Publication21-Aug-2017
 

How to cite this article:
Al-Mendalawi MD. A pediatric echocardiographic Z-score nomogram for a developing country: Indian pediatric echocardiography Study – The Z-score. Ann Pediatr Card 2017;10:314-5

How to cite this URL:
Al-Mendalawi MD. A pediatric echocardiographic Z-score nomogram for a developing country: Indian pediatric echocardiography Study – The Z-score. Ann Pediatr Card [serial online] 2017 [cited 2021 Aug 5];10:314-5. Available from: https://www.annalspc.com/text.asp?2017/10/3/314/213363




Sir,

I read with interest the study by Gokhroo et al. on the constructing pediatric echocardiographic Z-score nomogram in India.[1] Apart from a few limitations addressed by the authors, I presume that the following four limitations might additionally cast some suspicions on the study results and possibly introduce bias in the clinical decision-making process.

First, in the methodology, the authors stated that various echocardiographic measurements were expressed in relation to body surface area (BSA) calculated by Haycock's formula (BSA = weight 0.5378 × height 0.3964 × 0.024265).[1] It is worthy to mention that various formula are present in the clinical settings to calculate BSA, namely, Boyd, Mosteller, Gehan and George, Haycock, and Dubois-DuBois. Clinical evaluation revealed the different performance of each BSA estimation method in certain pediatric population.[2] The lack of a similar evaluation among pediatric population in India renders the suitability of using Haycock's formula to estimate BSA in the Gokhroo et al.'s study questionable.

Second, the studied cohort included 71% of boys and 29% of girls. Determination of gender-specific echocardiographic Z-score nomogram for the studied population was regrettably not addressed. This point is important to be considered as gender-specific differences in certain echocardiographic dimensions have been reported. For instance, boys have been found to have larger heart valve dimensions at all ages. These valve dimension differences were statistically significant for the three of four heart valves even after adjustment for the differences in body sizes. The difference might be due to higher circulating blood volume in boys compared to that in girls.[3]

Third, in the methodology, the authors mentioned that echocardiographic evaluation was performed using a Philips iE33 system (Philips Medical Systems, Bothell, WA, USA). The two-dimensional echocardiography and M-mode measurements of various cardiovascular structures were obtained for each participant.[1] It is noteworthy that the recent developments in three-dimensional echocardiography (3DE) have resulted in smaller probes, faster data acquisition, and wider applicability. A systematic literature search has pointed that in patients with a regular heart rhythm and for whom it was possible to obtain good quality images, the introduction of 3DE has improved the accuracy and reproducibility of the left ventricular volume and ejection fraction measurements. In valvular heart disease, the superiority of 3DE was also apparent but was less convincing.[4] I presume that if the authors employed 3DE in the methodology, the study results might be altered.

Fourth, it is obvious that Indian population is a unique amalgamation of different ethnic groups. It was not obvious in the study methodology the exact ethnicities of the studied population. This point is important to be considered as many echocardiographic parameters truly vary among different ethnic groups.[5]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gokhroo RK, Anantharaj A, Bisht D, Kishor K, Plakkal N, Aghoram R, et al. A pediatric echocardiographic Z-score nomogram for a developing country: Indian pediatric echocardiography study – The Z-score. Ann Pediatr Cardiol 2017;10:31-8.  Back to cited text no. 1
    
2.
Orimadegun A, Omisanjo A. Evaluation of five formulae for estimating body surface area of Nigerian children. Ann Med Health Sci Res 2014;4:889-98.  Back to cited text no. 2
  [Full text]  
3.
Zilberman MV, Khoury PR, Kimball RT. Two-dimensional echocardiographic valve measurements in healthy children: Gender-specific differences. Pediatr Cardiol 2005;26:356-60.  Back to cited text no. 3
    
4.
Ruddox V, Mathisen M, Bækkevar M, Aune E, Edvardsen T, Otterstad JE. Is 3D echocardiography superior to 2D echocardiography in general practice? A systematic review of studies published between 2007 and 2012. Int J Cardiol 2013;168:1306-15.  Back to cited text no. 4
    
5.
Cosyns B, Lancellotti P. Normal reference values for echocardiography: A call for comparison between ethnicities. Eur Heart J Cardiovasc Imaging 2016;17:523-4.  Back to cited text no. 5
    

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Correspondence Address:
Mahmood Dhahir Al-Mendalawi
Department of Paediatrics, Al-Kindy College of Medicine, University of Baghdad, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/apc.APC_23_17

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