READERS’ COMMENTS Coronary Plaque Composition: Multifactorial Contribution We read with interest the report by Qian et al 1 describing the effects of age and gender on virtual histologic assess- ment of coronary plaque composition. Although the question being addressed is of potential interest, a number of im- portant confounders are not detailed, making interpretation of the analysis difficult. This includes no reporting of the prevalence of unstable and stable coronary presentations in each group; differences in medications, including st- atins, between groups; and differences in cardiovascular risk factors between groups. Some or all of these factors are known to affect plaque composition and, if disproportionately present in the analyzed groups, could skew the analy- sis, leading to either important differ- ences being missed or incorrect inter- pretations of observed differences. Ravinay Bhindi, MBBS, PhD Michael R. Ward, MBBS, PhD Sydney, Australia 4 April 2009 1. Qian J, Maehara A, Mintz GS, Margolis MP, Lerman A, Rogers J, Banai S, Kazziha S, Castellanos C, Dani L, Fahy M, Stone GW, Leon MB. Impact of gender and age on in vivo virtual histology–intravascular ultra- sound imaging plaque characterization (from the global Virtual Histology Intravascular Ultrasound [VH-IVUS] Registry). Am J Car- diol 2009;103:1210 –1214. doi:10.1016/j.amjcard.2009.05.001 Multi-Plane Three-Dimensional and Four-Dimensional Echocardiography Against Multi-Slice Computed Tomography and Magnetic Resonance Angiography I read with great interest the report “Usefulness of Live Three-Dimensional Transesophageal Echocardiography in a Congenital Heart Disease Center” by Baker et al 1 in a recent issue of The American Journal of Cardiology. The investigators studied 27 cases, consist- ing of 16 interventional catheteriza- tions, 4 intraoperative studies, and 7 di- agnostic evaluations using 3-dimensional transesophageal echocardiography at a tertiary congenital heart disease center. All patients except 1 were successfully examined with adult-sized probes with- out general anesthesia, although the congenital defects examined were not complex as in interatrial defects. The diagnosis of congenital heart de- fects needs special attention and experi- ence in cardiology and radiology. For the diagnosis of congenital heart disease, var- ious imaging tools have been used, in- cluding invasive (cardiac catheterization), semi-invasive (computed tomography [CT], multislice CT), and noninvasive (echocardiography, magnetic resonance imaging [MRI]) imaging. All have advan- tages and disadvantages. Its invasive na- ture, use of ionizing radiation, and use of contrast agents are major disadvantages of catheterization. Ionizing radiation and contrast agents are also negative features of CT and multislice CT. Long process times, claustrophobia, and the exclusion of patients with cardiac pace- makers or implantable cardioverter-de- fibrillators are disadvantages of MRI. In- tra- and interobserver variability, inexperienced sonographers, and rela- tively poor temporal and spatial resolu- tion compared with radiologic tools are disadvantages of echocardiography. Re- cently, new technologies, such as mul- tislice CT and MRI with high spatial and temporal resolution, have been in- creasingly used for congenital heart dis- eases. 2,3 However, echocardiography should be the initial diagnostic tool, be- cause it is inexpensive and reproducible and demonstrates cardiac function in real time. The localization, relation to adjacent structures, and function of con- genital heart defects can be demon- strated on echocardiography. Especially with multiplane and 3-dimensional de- vices (3-dimensional and 4-dimensional echocardiography), anatomic relations and localization can be better defined. 4 The application of this technology to the transesophageal field has expanded the usefulness of echocardiography for diagnostic and interventional purposes. 1 In conclusion, 3-dimensional and 4-dimensional echocardiography, either transthoracic or transesophageal, should be the initial tool for diagnosis and in- tervention in congenital heart diseases. In case of insufficient diagnosis, other radiologic methods, such as multislice CT and MRI, can be used. Serkan Cay, MD Ankara, Turkey 5 April 2009 1. Baker GH, Shirali G, Ringewald JM, Hsia TY, Bandisode V. Usefulness of live three-dimen- sional transesophageal echocardiography in a congenital heart disease center. Am J Cardiol 2009;103:1025–1028. 2. Cay S, Ozturk S, Korkmaz S, Turkvatan A. Asymptomatic patent ductus arteriosus in a 41-year-old woman. Int J Cardiovasc Imaging 2006;22:283–285. 3. Cay S, Metin F, Korkmaz S. Images in cardi- ology. A common cause of secondary hyper- tension: coarctation of the aorta. Heart 2006; 92:734. 4. Cay S, Tufekcioglu O, Ozturk S, et al. Left ventricular diverticulum with contractile func- tion in an unusual site. J Am Soc Echocardiogr 2006;19:1293.e3–1293.e6. doi:10.1016/j.amjcard.2009.04.004 Seasonal Variation in Lipids: Should We Consider It More? We read with interest the report by Tung et al, 1 describing seasonal variation in the lipid status of a cohort of patients enrolled in the Pravastatin or Atorvastatin Evaluation and Infection Therapy– Thrombolysis in Myocardial Infarction 22 (PROVE-IT–TIMI-22) study. The in- vestigators found no differences in lipid levels at baseline, but with treatment, low-density lipoprotein (LDL) choles- terol levels were significantly higher in winter than in summer (+6.25% and +9.7% in the pravastatin and atorvastatin groups, respectively, p 0.001 for each), whereas high-density lipoprotein choles- terol was higher in summer than in winter (+4.87%, p 0.001). Moreover, the achievement of optimal LDL choles- terol levels was significantly higher in summer than in winter (+4.87% and +7.69% in the pravastatin and atorva- statin groups, respectively). A slight seasonal variation in blood lipid levels, characterized by a peak in winter and a trough in summer (with amplitude val- ues of 1.8% and 2.5% of the average cholesterol levels, respectively) was also reported by Ockene et al, 2 in a cohort of 517 younger and healthy vol- unteers. However, a particularly inter- esting finding from this study was that subjects with cholesterol levels 240 mg/dl showed a higher relative increase in winter, especially women (47% vs 7% in men), and about 22% more sub- Am J Cardiol 2009;104:739 –744 www.AJConline.org 0002-9149/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved.