We thank Dr. Finsterer and Dr. Stöllberger for their comments regarding the case report, but we believe a number of points require comment. Firstly, we believe that isolated noncompaction of the left ventricle (INCV) and left ventricular hypertrabeculation (LVHT) are not one and the same. The diagnostic criteria for INCV are as stated in our report, and were originally described by Oeschlin 1 and Jenni 2. Our case fulfilled the criteria for noncompaction, with the endsystolic ratio of the compacted to the noncompacted layer taken using the apical four chamber view, trabeculations in the apical and lateral region, blood flow within the deep intertrabecular recesses and akinesis of the segments. Our discussion was thus confined to INCV, whereas the letter largely concerns LVHT. LVHT is defined as greater than three prominent trabeculations 3, is associated with neuromuscular conditions 4 and INCV is not commonly associated with neuromuscular conditions, hence the omission of neuromuscular disease in our discussion. INCV falls under the WHO classification as “noncompacted myocardium”, a distinct entity. It should be noted that this classification places cardiomyopathies associated with neuromuscular or metabolic disorders as specific cardiomyopathies 5. Strict adherence to the definition will prevent unnecessary misdiagnosis. Secondly, whilst Finsterer and Stöllberger point out that they have identified LVHT in patients over 90, they acknowledge that this observation is unpublished and when strictly defined INCV is considered, diagnosis in the elderly remains unusual with no previously reported cases in octogenarians. Thirdly, we believe the discrepancy between thromboembolic risk reported when the strict definition of INCV is followed 1 and that reported by Stöllberger and Finsterer 6 is due to the abnormal left ventricular systolic function commonly seen in the group with INCV, frequently absent in the LVHT population. We agree that atrial fibrillation and left ventricular systolic dysfunction in the presence of INCV are the principle indications for anticoagulation rather than the presence of trabeculae themselves. Fourthly, disease prevalence is likely to vary from centre to centre, based upon referral patterns, but more importantly based on diagnostic criteria used. Given Finsterer and Stöllberger's expertise and experience with this LVHT, it is likely that referral bias does exist, in part explaining the greater than expected prevalence in their series. Also the criteria for INCV is much more rigorous than LVHT, hence confusing the definition will overestimate the prevalence of the condition. Fifthly, the question of prognosis again depends upon the diagnostic criteria used and how cases are discovered. A poor prognosis has been observed in some series of INVC 1 once the diagnosis is made. This may reflect the fact that the diagnosis is usually only made once the patient presents with heart failure. Our case suggests that INCV may be a benign process for many years, with this gentlemen living to 81 years, and only when myocardial function had deteriorated and heart failure had developed did his outlook deteriorate. An autopsy was not performed hence we can only speculate as to the cause of death, but we presume it to be arrhythmic in view of its sudden nature. We frequently see very mildly elevated troponin levels in cases of heart failure and pulmonary oedema, even in the absence of coronary disease, which may explain the elevated troponin with normal creatine kinase levels. The presence of underlying coronary disease cannot however be excluded. We also agree that ACE inhibitors should be used to treat heart failure with left ventricular systolic dysfunction, although it should be noted that there is no specific evidence to support the efficacy of this treatment in the group of patients with INCV. Finally, INCV is an important, albeit rare, cardiomyopathy. The major point of this case report was to highlight the necessity for echocardiography in order to assist in accurate diagnosis, assessment of prognosis and treatment of patients with congestive cardiac failure, regardless of age, in an attempt to ensure that all patients receive appropriate evidenced based treatments. What the letter from Finsterer and Stöllberger highlights is that there is diagnostic confusion between INCV and LVHT which leads to uncertainty about important factors such as causes, prevalence and prognosis. We therefore agree that further discussion and research in this area is required.