773 Rapid and sustained restoration of anterograde coronary blood flow in the territory of the infarct- related artery (IRA) remains the most effective treat- ment for acute myocardial infarction (AMI). 1 How- ever, coronary angiography is of limited value in assessing the success of reperfusion.Several echocar- diographic, scintigraphic, and contrast-enhanced magnetic resonance studies have shown that about one sixth to one fourth of patients with Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow show poor tissue perfusion (“no-reflow and low-reflow” phenomenon), which hampers the improvement of myocardial function. 2-6 Thus the best approach to examine the success of coronary procedures is to assess the reestablishment of tissue-level perfusion within the jeopardized myocardium.Of the few avail- able methods capable of assessing microvascular integrity, myocardial contrast echocardiography (MCE) belongs to the most promising because con- trast microbubbles are pure intravascular tracers, 7 and they improve the signal-to-noise ratio between flowing blood and surrounding tissue. However, the current published studies of MCE on “no-reflow” in human beings were performed with the use of intra- Assessment of No-Reflow Phenomenon After Acute Myocardial Infarction with Harmonic Angiography and Intravenous Pump Infusion with Levovist: Comparison with Intracoronary Contrast Injection Luciano Agati, MD, Stefania Funaro, MD, and Federico Bilotta, PhD, MD, Rome Italy From the Department of Cardiology, “La Sapienza” University of Rome, Italy. Reprint requests: Luciano Agati, MD, Echocardiography Labora- tory, Department of Cardiology, “La Sapienza” University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy (E-mail: Luciano.Agati@uniroma1.it). Copyright © 2001 by the American Society of Echocardiography. 0894-7317/2001/$35.00 + 0 27/1/113235 doi:10.1067/mje.2001.113235 Myocardial contrast echocardiography (intracoro- nary application) has emerged as an accurate method to detect the “no-reflow phenomenon.” To investi- gate the diagnostic value of harmonic angiography after intravenous infusion of Levovist in assessing “no-reflow,” both intracoronary and intravenous contrast injections were performed in a group of patients with acute myocardial infarction. Seven- teen consecutive patients with a successfully reper- fused acute myocardial infarction within 6 hours of symptom onset were selected for this study. All patients underwent contrast echocardiography with harmonic angiography with Levovist (400 mg/mL, intravenous pump infusion, trigger intervals 1:4 to 1:8) and sonicated albumin (0.5 to 1 mL, intracoro- nary bolus) on day 1 after the achievement of a sustained coronary reflow. Myocardial perfusion was qualitatively assessed with a 12-segment model. The endocardial length of the residual contrast de- fect after reflow was also calculated. Forty-four of 204 segments were not analyzed after intravenous contrast echocardiography and 37 after intracoro- nary contrast echocardiography because of artifacts. Intracoronary and intravenous injections showed a perfusion defect in 31 (19%) segments, with a con- cordance of 89% (κ coefficient, 0.72). Concordance in anteroseptal, anterolateral, and inferolateral seg- ments was 95% (κ = 0.92), 88% (κ = 0.66), and 83% (κ = 0.57), respectively. With intracoronary injection used as the reference method, intravenous injection had a sensitivity of 74% and a specificity of 93% for diagnosing contrast defects. The endocardial extent of no-reflow was 18 ± 19 after intravenous and 21 ± 17 after intracoronary contrast echocardiography (P = not significant). Intravenous contrast echo- cardiography with Levovist reliably identifies the no-reflow phenomenon after successful reper- fusion, especially in acute anteroseptal myocardial infarction. (J Am Soc Echocardiogr 2001;14:773-81.)