Identification of viable myocardium by perfusion imaging with intravenous contrast echocardiography after acute myocardial infarction

Myocardial perfusion contrast echocardiography is evolving into an effective method for the evaluation of myocardial blood flow after acute coronary events. The direct injection of ultrasound contrast agents into the aortic and coronary circulation has been shown to accurately identify areas of viable myocardial tissue. Recently, intravenous ultrasound contrast has been found to be useful in detecting microvascular blood flow after the restoration of blood flow in patients with myocardial infarction. We present the case of a patient in whom intravenous ultrasound contrast assisted in the detection of viable myocardial tissue after an acute ischemic syndrome.     

Optimal time for predicting myocardial viability after successful primary angioplasty in acute myocardial infarction: a study using myocardial contrast echocardiography

This study sought to elucidate serial changes in microvascular integrity during papaverine-induced hyperemia in the risk area for myocardial infarction. In addition, we attempted to determine the optimal time for predicting myocardial viability. Seventy-two patients who underwent serial myocardial contrast echocardiography (MCE) before and shortly after (day 1), 1 day (day 2), and 3 weeks (day 21) after recanalization were studied. In 18 of 72 patients, MCE was performed at baseline and during hyperemia using selective intracoronary infusion of papaverine. Both the peak grayscale ratio (PGSR) within the risk area, and the no- and low-reflow ratio (LR ratio) were analyzed in each stage. Left ventricular regional wall motion (RWM) was determined 6 months after recanalization. The correlation coefficient between PGSR with papaverine on day 1 and that on day 2 was 0.54 (p = 0.02); it was 0.50 (p = 0.04) between day 1 and day 21, and 0.82 (p = 0.001) between day 2 and day 21. On day 1, the correlation coefficient between the LR ratio with papaverine and RWM was 0.60 (p = 0.02), which changed to 0.72 (p = 0.003) on day 2 and 0.54 (p = 0.04) on day 21, respectively. The best time to predict viable myocardium was established on day 2 by receiver operating characteristics curves. ST-segment re-elevation, elapsed time from onset to recanalization, and antecedent angina pectoris were independent factors for PGSR on day 2 using stepwise and multiple linear regression analysis. This study suggests that the optimal time to estimate microvascular integrity for predicting myocardial viability might be 1 day after recanalization, which is neither shortly after recanalization nor during the convalescent stage.     

Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction

OBJECTIVES: We sought to evaluate and validate the ability of the angiographic myocardial blush grade to risk stratify patients after successful angioplasty in acute myocardial infarction (AMI). BACKGROUND: Although epicardial Thrombolysis In Myocardial Infarction (TIMI)-3 flow is restored in >90% of patients undergoing primary percutaneous coronary intervention (PCI), normal myocardial perfusion may be present less frequently and may detrimentally impact survival. METHODS: A cohort of 173 consecutive patients undergoing intervention within 24 h of AMI onset were studied. High-risk features of this population included failed thrombolysis in 39%, cardiogenic shock in 17% and saphenous vein graft culprit in 11% of patients. RESULTS: Despite the restoration of TIMI-3 flow in 163 (94.2%) patients, myocardial perfusion, as evidenced by normal contrast opacification of the myocardial bed subtended by the infarct artery (myocardial blush), was normal in only 29.4% of patients with TIMI-3 flow following PCI, and in no patient with TIMI 0 to 2 flow. In patients in whom TIMI-3 flow was restored, survival was strongly dependent on the myocardial perfusion grade; one-year cumulative mortality was 6.8% with normal myocardial blush, 13.2% with reduced myocardial blush and 18.3% in patients with absent myocardial blush (p = 0.004). CONCLUSIONS: Abnormal myocardial perfusion is present in most patients following primary or rescue PCI in AMI, despite restoration of brisk epicardial coronary flow. In high risk patients achieving TIMI-3 flow after intervention, the myocardial blush score may be used to stratify prognosis into excellent, intermediate and poor survival. Further study is warranted to examine whether adjunctive mechanical or pharmacologic strategies can further improve myocardial perfusion and survival of patients with acute myocardial infarction undergoing intervention.     

Quantitative assessment of myocardial perfusion during graded coronary artery stenoses by intravenous myocardial contrast echocardiography

OBJECTIVES: The purpose of this study was to examine whether coronary stenoses of variable severity could be quantitatively assessed by analysis of myocardial perfusion as determined by intravenous (IV) myocardial contrast echocardiography. BACKGROUND: Recently, new contrast agents and imaging technology have been developed that may enable improved assessment of myocardial perfusion by IV contrast injection. METHODS: Variable obstruction of the left anterior descending (LAD) coronary artery in dogs was produced by a screw occluder. Coronary artery flow was measured with a transit time flowmeter during baseline, pharmacological vasodilation, a non-flow-limiting stenosis at rest in conjunction with vasodilation, a flow-limiting stenosis, and total occlusion. Myocardial contrast echocardiography was performed after IV injection of the contrast agent NC 100100. Time-intensity curves were obtained off-line for the LAD risk area and the adjacent left circumflex (LCx) territory, and peak background-subtracted video intensity was determined. Fluorescent microspheres were injected at each intervention for determination of regional myocardial blood flow. RESULTS: During non-flow-limiting stenosis, flow limiting stenosis and total occlusion, LAD/LCx ratios of peak myocardial videointensity and blood flow decreased proportionately. Both LAD/LCx ratios of video intensity and blood flow identified the non-flow-limiting and the flow-limiting stenoses as well as total occlusion of the LAD artery. A significant correlation between LAD/LCx video intensity and blood flow ratios was observed (r = 0.83, p < 0.0001). CONCLUSIONS: The degree of blood flow mismatch between ischemic and normal myocardial regions during graded coronary stenoses can be estimated in the dog by quantitative assessment of myocardial perfusion produced by IV myocardial contrast echocardiography.     

Myocardial perfusion assessed by contrast echocardiography correlates with angiographic perfusion parameters in patients with a first acute myocardial infarction successfully treated with angioplasty

BACKGROUND:

Angiographic flow in an epicardial artery does not define perfusion at the microvascular level.

AIM:

To compare myocardial contrast echocardiography (MCE) with angiographic methods of assessing microvascular reperfusion in patients with acute myocardial infarction (AMI).

METHODS:

One hundred consecutive patients with a first ST segment elevation myocardial infarction and single-vessel disease were successfully treated with primary percutaneous coronary intervention. Regional contrast score index (RCSI), corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC), TIMI myocardial perfusion grade (TMPG) and myocardial blush grade were evaluated.

RESULTS:

Among 717 asynergic segments on MCE, 168 revealed a lack of perfusion. TMPG and cTFC correlated significantly with RCSI (P=0.031 and P=0.027, respectively). Myocardial blush grade did not correlate with RCSI (P=0.067). Patients with anterior AMI had significantly more segments with a perfusion defect on MCE than patients with inferior AMI (P=0.0001).

CONCLUSIONS:

MCE results correlate with angiographic methods of perfusion assessment such as TMPG and cTFC. Anterior AMI is associated with a greater extent of perfusion defect. MCE results correlate also with recovery of systolic left ventricular function and clinical outcome at six month follow-up.     

经静脉心肌声学造影评价心肌梗死后存活心肌的价值

目的　探讨经静脉心肌声学造影 (MCE)对心肌梗死后存活心肌的诊断价值。方法　 2 4例心肌梗死患者用二维超声评价室壁运动情况 ,同时经静脉进行MCE ,以 3个月后静态超声心动图左室心肌节段性运动改善为依据评价MCE对心肌梗死后存活心肌的诊断价值。结果　在 2 4例病人的 384个心肌节段中 ,运动异常节段 184个。在运动异常的 184个节段中 ,MCE1分 39段 ,0 5分 5 0段 ,0分 95段。 3个月复查 79个节段有运动改善 ,其中 39段来自MCE1分的心肌 ,4 0段来自MCE0 5分的心肌。MCE对预测心肌梗死后室壁运动改善的敏感性、特异性、阳性预测值、阴性预测值及准确率分别为 :10 0 %、89 7%、84 8%、10 0 %和 94 6 %。结论　MCE能比较准确地预测心肌梗死后心肌的存活性     

Recovery of regional myocardial dysfunction after successful coronary angioplasty early after a non-Q wave myocardial infarction

More aggressive therapy has been suggested for patients who have a non-Q wave myocardial infarction (MI) because of the frequency of subsequent unstable angina, recurrent MI, and high mortality rate compared to patients with Q wave MI. The present study was undertaken to investigate the effect of coronary angioplasty on regional myocardial function of the infarct zone in patients with angina early after a non-Q wave MI. The study population consisted of 36 patients undergoing successful coronary angioplasty within 30 days of a non-Q wave MI, in whom sequential left ventricular angiograms of adequate quality were obtained before the initial procedure and at follow-up angiography. The global ejection fraction increased significantly from 60 +/- 9% to 67 +/- 6% (p = 0.0003). This significant increase in the global ejection fraction was primarily due to a significant improvement in the regional myocardial function of the infarct zone. The results of the present study show not only that ischemic attacks early after a non-Q wave MI may lead to prolonged regional myocardial dysfunction but more important that this depressed myocardium has the potential to achieve normal contraction after successful coronary angioplasty.     

心肌声学造影对冠状动脉血运重建术心肌灌注的评价研究

目的探讨心肌声学造影（MCE）评估缺血心肌血运重建后心肌灌注的价值。方法 36例缺血性心肌病患者分别予以冠状动脉支架置入术或冠状动脉旁路移植术进行血运重建,在术前、术后早期（〈1个月）、及术后晚期（6～12）个月分别行实时MCE检查,根据造影剂的充盈程度进行评分。将其结果与相应阶段造影（CAG）和（或）冠脉增强CT成像（CTA）结果进行对照分析。结果按16段心肌节段法进行分段分析测量。36例患者576个节段中,运动异常节段247个,MCE结果与治疗前冠脉造影吻合率为89.89%。冠脉血管再通术后早期共有172个节段有改善,与冠状动脉支架置入术或冠状动脉旁路移植术靶血管供血支配区吻合率为78.00%。术后晚期,MCE与冠脉影像结果吻合率为80.56%。结论实时MCE可随访观察冠状动脉再通血运重建缺血心肌血流灌注改善的情况,可尝试用于冠心病血管重建术后的临床随访。     

Usefulness of quantitative intravenous myocardial contrast echocardiography to analyze microvasculature perfusion in patients with a recent myocardial infarction and an open infarct-related artery: comparison with intracoronary myocardial contrast echocardiography.

AIMS: We analyzed the usefulness of quantitative intravenous myocardial contrast echocardiography to study microvasculature perfusion after infarction in comparison with intracoronary myocardial contrast echocardiography. METHODS AND RESULTS: Thirty-two patients with a first ST elevation myocardial infarction, single-vessel disease and an open artery (TIMI 3) were studied before discharge. Myocardial perfusion in the risk area was quantified with intracoronary and intravenous myocardial contrast echocardiography. Perfusion was normal (intracoronary contrast echocardiography normalized videointensity >0.75) in 78 out of 97 dysfunctional segments (80%). Sensitivity and specificity of intravenous contrast echocardiography to predict normal perfusion were 87% and 63% for 'first-pass myocardial blood flow' (upslope of contrast arrival x peak intensity after intravenous bolus injection of contrast) and 91% and 89% for end-systolic single-triggered images captured every 6 cycles, respectively. In an analysis per patients, normal perfusion (0 or 1 hypoperfused segments with intracoronary contrast echocardiography) was observed in 22 cases (69%). End-systolic single-triggered images showed a strong correlation with intracoronary contrast echocardiography (R2 = 0.82, p = 0.0001). CONCLUSIONS: Intravenous contrast echocardiography is a useful technique to analyze microvasculature perfusion soon after infarction. A quantitative analysis of single-triggered images is an easy-to-obtain and reliable method to define perfusion when compared with intracoronary contrast echocardiography.     

Myocardial viability after primary coronary angioplasty: low-dose dobutamine stress echocardiography versus myocardial contrast echocardiography.

BACKGROUND: Successful reperfusion therapy in patients with acute myocardial infarction (AMI) improves survival. Indeed, after AMI myocardial dysfunction may be reversible (hibernating or stunned myocardium). Low-dose dobutamine stress echocardiography (LDDSE) provides us with the possibility of evaluating viable myocardial segments, while myocardial contrast echocardiography (MCE) allows the study of the microcirculation in the same myocardial areas. The aim of our study was to compare LDDSE and MCE, in the prediction of the recovery of segments in patients with AMI who were submitted to primary coronary angioplasty (PTCA). METHODS: We studied 14 patients with AMI. Both LDDSE and MCE with Levovist were performed after primary PTCA. The viability gold standard was a recovery of contractility detected at echocardiography 2 months later. RESULTS: For LDDSE, the sensitivity was 91%, the specificity 71% and the positive and negative predictive values were 93 and 64% respectively. For MCE, the sensitivity was 94%, the specificity 44%, the positive predictive value 89%, and the negative predictive value 59%. Two tests agreed in 81% of the cases. Stress echocardiography and contrast echocardiography agreed in 81% of cases. CONCLUSIONS: LDDSE has a very good positive accuracy, it has an acceptable negative predictive value and is relatively cheap. On the other hand, MCE has a good positive accuracy, but a low negative accuracy and carries a high cost. The integration of these two tests, which are too expensive in clinical practice, could improve our comprehension of the post-PTCA pathophysiology.     

Left ventricular wall motion improvement after successful coronary reperfusion therapy in acute myocardial infarction: prediction by two-dimensional echocardiography]

Two-dimensional echocardiography was performed in 21 patients with acute anterior myocardial infarction who underwent intracoronary reperfusion therapy for the infarct-related left anterior descending coronary artery. The images of left ventricular wall was subdivided into 15 segments according to Heger's classification, and the wall motion of the 6 segments corresponding to the perfusion region was visually inspected before and mean 5.9 weeks after coronary intervention. The patients were categorized in 2 groups on the basis of an increase attained in wall motion score of the 6 segments; a group of patients who improved by an increase of 2 points (14 cases) and those who did not improve, not reaching a 2-point increase (7 cases). Three parameters including wall thickness of the infarcted regions, the ratio of the interventricular septum (IVS) to the posterior wall thicknesses, and the systolic wall thickening rate of the septum measured during the acute phase were compared between the 2 groups. In the improved group, the wall thickness of the infarcted region was 9.1 +/- 1.5 mm; whereas, in the unimproved group it was significantly less (7.6 +/- 1.1 mm). The ratio of the septum to posterior wall thicknesses in the improved group (0.88 +/- 0.12) was significantly greater than that of the unimproved group (0.74 +/- 0.11). No significant difference was observed in the systolic wall thickening rate. We concluded that the measurement of wall thickness of the infarcted region in the acute phase in patients with acute anterior myocardial infarction may be useful for predicting the restoration of wall motion after intracoronary reperfusion therapy.     

Coronary perfusion during acute myocardial infarction with a combined therapy of coronary angioplasty and high-dose intravenous streptokinase

Two hundred and sixteen patients with acute myocardial infarction were treated with immediate infusion of high-dose (1.5 million units) intravenous streptokinase followed by emergency coronary angioplasty. The infarct lesion was crossed and dilated in 99% and persistent coronary perfusion after the procedure was achieved in 90% (including 3% with significant residual stenosis). Total in-hospital mortality was 12%. Multivariable analysis showed a higher hospital mortality with cardiogenic shock (41% vs 5% without shock), older age, lower left ventricular ejection fraction, and female sex. Final patency of the infarct-related vessel was determined by follow-up in-hospital cardiac catheterization. Coronary reocclusion occurred in 11% (symptomatic in 7%, treated with emergency angioplasty or bypass surgery; silent in 4%, treated medically). Of the surviving patients with successful initial establishment of infarct vessel patency, 94% were discharged from the hospital with an open infarct artery or a bypass graft to the infarct vessel. There was significant improvement in both ejection fraction (44% to 49%; p less than .0001) and regional wall motion in the infarct zone (-3.0 SD to -2.4 SD; p less than .0001) among patients with persistent coronary perfusion and insignificant residual stenosis at the time of the follow-up cardiac catheterization. Thus, a treatment strategy for acute myocardial infarction that includes immediate administration of streptokinase followed by emergency coronary angioplasty, and coronary bypass surgery when necessary, results in a high rate of early and sustained patency of the infarct-related vessel.     

Study of post-infarction coronary perfusion using quantitative analysis of myocardial echocardiography with intravenous injection of contrast

INTRODUCTION AND OBJECTIVES: After a myocardial infarction, damage to the microcirculation indicates a worse prognosis. We compared the usefulness of the quantitative analysis of myocardial contrast echocardiography with intravenous injection of contrast (MCE-iv) with intracoronary injection (MCE-ic) for analyzing coronary perfusion. PATIENTS AND METHOD: We studied 42 patients with a first ST-elevation myocardial infarction, single-vessel disease and a patent artery (TIMI 3, stenosis < 50%). Myocardial perfusion in segments in the infarct-related area was quantified (normalized scale 0-1) with MCE-ic (bolus of Levovist, real-time imaging, perfusion considered normal if > 0.75) and MCE-iv (perfusion of SonoVue, single-image capture in 1 out of each 6 cycles with trigger set at end-systole, perfusion considered normal if > 0.9). Perfusion was considered abnormal if 2 or more segments showed altered perfusion. RESULTS: Quantification with MCE-iv took 5 +/- 1 minutes. No side effects were observed. MCE-ic was normal in 141 segments (80%) out of 176 segments included in the infarcted area, whereas 35 segments (20%) showed abnormal perfusion. MCE-ic was normal in 31 patients (74%) and was altered in 11 cases (26%). Normal perfusion with MCE-iv had a sensitivity of 91%, a specificity of 84% and a kappa index of 0.67 for predicting normal perfusion with MCE-ic (r = 0.86; P < .0001 between the two techniques). CONCLUSIONS: In comparison with MCE-ic, quantitative analysis of single images captured during intravenous perfusion of contrast is an easy, rapid and valid method for analyzing postinfarction coronary perfusion.     

Assessment of right ventricular perfusion after right coronary artery occlusion by myocardial contrast echocardiography

OBJECTIVES: The purpose of this study was to examine the ability of myocardial contrast echocardiography (MCE) to assess right ventricular (RV) perfusion. BACKGROUND: Although MCE can readily assess left ventricular perfusion abnormalities, there are no data regarding the ability to assess RV perfusion abnormalities. METHODS: The right coronary artery (RCA) was occluded in 10 open-chest dogs. Myocardial contrast echocardiography was performed with 0.27 g/min Levovist infusion by harmonic power Doppler with electrocardiographically gated intermittent triggered imaging at pulsing intervals ranging from 1:1 to 1:20 at baseline and 90 min after RCA occlusion. Video-intensity of the RV wall was plotted against pulsing intervals and was fitted to an exponential function: y = A(1-exp(-bt)), where A is the plateau video-intensity and b is the rate of video-intensity rise. Myocardial contrast echocardiography and microsphere-derived myocardial blood flow (MBF) measurements were performed at baseline and 90 min after RCA occlusion. RESULTS: Because the severity of RV perfusion abnormalities assessed by MBF varied during RCA occlusion, diverse grades of patchy opacification defects were observed by MCE. The RV wall thickness decreased, and the RV dimension increased, after RCA occlusion in each dog. The correlation of occlusion to baseline MBF ratios in the RV wall was closer to the ratio of b (r = 0.897, p = 0.0004) than A (r = 0.767, p = 0.0097) and was the closest to the ratio of Axb (r = 0.935, p < 0.0001). CONCLUSIONS: The RCA occlusion is manifested by RV wall thinning and dilation as well as by perfusion abnormalities consisting of patchy opacification defects by MCE. Myocardial contrast echocardiography-derived refilling parameters can be applied to assess RV perfusion abnormalities produced by RCA occlusion.     

Optimal time for predicting left ventricular remodeling after successful primary coronary angioplasty in acute myocardial infarction using serial myocardial contrast echocardiography and magnetic resonance imaging.

The objective of this study was to determine the optimal time to assess microvascular integrity within the risk area for myocardial infarction in order to predict unfavorable left ventricular remodeling (LVR) after successful primary coronary angioplasty. Fifty-three patients who underwent myocardial contrast echocardiography (MCE) just before recanalization, shortly after and 1 day (Day 2) and 3 weeks after recanalization were studied. The no- and low-reflow ratio (LR ratio) was analyzed at each stage. The wall-thinning ratio within the risk area was determined using magnetic resonance imaging performed 3-4 weeks after the recanalization. Thirteen of the 53 patients showed LVR 3-8 months after recanalization. The optimal time to predict LVR was found to be Day 2 based on the receiver operating characteristic curves. The LR ratio on Day 2 (chi2=7.39, p=0.007) and the collateral circulation before recanalization (chi2=4.57, p=0.03) were chosen as independent variables for predicting LVR. Patients with greater than 0.43 in the LR ratio on Day 2 showed a lower wall-thinning ratio (58+/-19% vs 72+/-20%, p=0.05). This study shows that the optimal time to estimate the microvascular integrity for predicting LVR is 1 day after recanalization, which is neither shortly after recanalization nor during the convalescent stage.     

Early evaluation of coronary microcirculation by echocardiography with contrast medium in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty

AIM: In about 30% of patients with ST elevated myocardial infarction (STEMI), in which a TIMI 3 flow is obtained in the infarct related artery (IRA) after primary percutaneous transluminal coronary angioplasty (PTCA), it's not possible to obtain a good perfusion of coronary microcirculation (no reflow). Aim of the study is to estimate the prognostic value of microcirculation study by echocardiography with contrast medium (MCE) within 48 h from procedure and to point out if there're clinical or procedural factors correlated with no reflow. METHODS: From February 2002 to June 2003 we have analyzed the integrity of microcirculation by MCE in patients with STEMI treated with PTCA. We have included in this study 62 patients with anterior myocardial infarction (MI) (first event), within 12 h from symptoms onset, with great echocardiographic window and TIMI 3 flow in the IRA after PTCA, excluding shock. We have obtained the evaluation of myocardial perfusion by MCE within 48 h from the treatment. We have used Sonovue as contrast medium, infused through peripheral vein. In each patient we have measured: perfusion index (PI) (sum of single segments scores divided by total number of myocardial segments) and regional perfusion index (RPI) (number of normal perfused segments between the diskinetic ones divided by diskinetic segments). RPI varies from 0 to 1: when >0.5 it has been considered index of good perfusion. Ejection fraction (EF) and wall motion score index (WMSI) have been calculated within 48 h and at 6 weeks follow up. ST resolution (STR) has been evaluated at 90 min from procedure and it was considered significant when >70%. RESULTS: Patients have been divided into 2 groups by myocardial perfusion: group R (33 patients with RPI>0.5) and group NR (29 patients with RPI =/<0.5). The 2 groups were similar for age (group R: mean age 61 years old; group NR: mean age 64 years old, P=n.s.), glycoprotein inhibitors use (group R 90%, group NR 97%, P=n.s.), diabetes (group R 12%, group NR 17%, P=n.s.), hypertension (group R 22%, group NR 23%, P=n.s.), incomplete revascularization (group R 12%, group NR 10%, P=n.s.). Group NR has shown a major women percentage (33%) than group R (9%) P=0.026. In group R we have appreciated a trend to a major percentage of TIMI 2-3 flow preprocedure (66% vs 36%, P=n.s.), a shorter ischemic time (209 min vs 258 min, P=n.s.) and a major STR at 90 min (72% vs 53%, P=n.s.), not statistically significant. Echocardiographic analysis and MCE show a better myocardial perfusion in group R (RPI 0.7 vs 0.14 and PI 0.96 vs 0.86, P<0.0001); better left ventricular kinetics at 6 weeks follow up (EF 54.2% vs 50.8%, P=n.s. and WMSI 1.07 vs 1.2, P=0.014) but not in the acute phase (EF 46.8 vs 42.9 and WMSI 1.3 vs 1.34, P=n.s.) 30 days mortality is similar in the 2 groups (both 3%). CONCLUSIONS: Myocardial perfusion evaluation correlates with left ventricular contractility measured at 6 weeks from acute MI, but doesn't correlate with contractility in the acute phase or 30 days mortality.     

Contrast echocardiography for evaluation of myocardial perfusion: effects of coronary angioplasty

Assessment of viable myocardium before and after interventional therapy has become a critical issue in modern cardiology. This report describes a new contrast echocardiographic technique using conventional two-dimensional imaging during direct intracoronary injections of small volumes (1.5 to 2.0 cc) of sonicated Renografin-76. Contrast echocardiography was performed before and after coronary angioplasty in seven patients with single vessel coronary artery disease. Before angioplasty a contrast (that is, perfusion) defect was noted in all seven patients. This defect correlated with the anatomic distribution of the epicardial coronary stenosis. After angioplasty the mean gradient across the stenotic lesion decreased from 52 +/- 11 to 13 +/- 14 mm Hg (p less than 0.01) in association with a fall in the mean diameter of the lesion from 84 +/- 8 to 29 +/- 13% (p less than 0.001). Increased myocardial perfusion to the area of "contrast defect" was demonstrated in only five of the seven patients, despite hemodynamically and angiographically successful angioplasty. Thus, contrast echocardiographic techniques performed during interventional therapy and used in conjunction with standard coronary angiographic procedures may provide additional physiologic information regarding regional myocardial perfusion after attempts at revascularization.