C  2008, the Authors Journal compilation C  2008, Blackwell Publishing, Inc. DOI: 10.1111/j.1540-8175.2008.00642.x Tissue Doppler Has an Important Prognostic Value in Patients with Beta Thalassemia To the Editor: We read the Letter to the Editor regarding our article “Right ventricular function in pa- tients with beta thalassemia: Relation to serum ferritin level,” which has been published in Echocardiography 2007;24:795–801. The authors of this “letter to the editor” included an important article on “Prognos- tic value of Doppler-demonstrated left versus biventricular restrictive filling pattern in tha- lassemia major.” They referred to their pre- viously published interesting work, 1 “Survival in thalassemia major patients,” where they re- ported lower 15-year cumulative survival rate in patients with biventricular restrictive filling pattern (RFP) compared to those with only left ventricular RFP, or those without RFP in either ventricle. In this work, none of their patients had isolated right ventricular RFP at baseline. We think these findings might point to the late occurrence of this pattern in the right ventri- cle (RV) and to the sequence of development of ventricular dysfunction in the two ventricles in beta thalassemia (β -Th) patients. As previously reported, 2,3 in β -Th patients, cardiac function may remain normal until late in the disease process. A previous study 4 conducted on 27 β -Th pa- tients (mean age 12.3 ± 5.0 years) with nor- mal ejection fraction, and 14 normal subjects has demonstrated reduction of systolic strain in the left ventricular (LV) wall, but no re- duction of systolic strain in the RV wall com- pared to the normal subjects. On the other hand, the RV late diastolic myocardial veloc- ity was increased, and the ratio of early to late myocardial velocity was decreased com- pared to normal subjects. Thus, this study highlighted the pattern of early changes in β - Th patients and concluded that those patients have changes denoting early systolic dysfunc- tion of the LV and early diastolic dysfunction of the RV, and also pointed to the ability of tis- sue Doppler modalities including strain imag- ing to detect such early changes of ventricular function before the development of overt heart failure. As mentioned in the letter to the editor, in our study, we did not evaluate the impact of cardiac dysfunction on survival of β -Th patients. Our aim was to evaluate RV function and its relation to serum ferritin level in those patients. The mean age of our study patients was 11.7 ± 5.1 years. We highlighted the early changes in the RV function in those patients as a whole group, reflecting alteration toward relaxation abnor- mality of diastolic performance. The group with higher serum ferritin level had lower RV sys- tolic myocardial velocity compared to the group with lower serum ferritin level, indicating early changes reflecting alteration of systolic function with the more iron overload. This iron overload is logically progressive with the disease pro- gression and is supposed to lead to the RFP with progression of age of these patients. Of note are two important facts. First, in most cardiac disorders that lead to alteration of di- astolic performance, the pattern of dysfunction progresses from relaxation abnormality to RFP with progression of the disease process. Sec- ond, RFP is commonly associated with some degree of systolic impairment even if this sys- tolic impairment is not associated with overt heart failure. The RFP is easily detected by tis- sue Doppler imaging, so follow-up of β -Th pa- tients with this imaging modality to search for progressive reduction of early and late diastolic myocardial velocities, in addition to periodic evaluation of serum ferritin level, would have an important prognostic value in these patients and help decision making about treatment in- cluding iron chelating therapy. Amal M. Hamdy, M.D. ∗ Maha Y. Zein El-Abdin, M.D. † and Manal A. Abdel-Hafez, M.D. † ∗ Cardiology Department and † Pediatric Department, Faculty of Medicine Al-Azhar University, Cairo, Egypt 554 ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech. Vol. 25, No. 5, 2008