90% of myocardial blood volume is found in the capillaries  and the concentration of microbubbles within the myocardium is reflected by the contrast signal . When the myocardium is fully saturated during contrast infusion, the signal intensity thus reflects the capillary blood volume. If these microbubbles are intentionally destroyed by a high power ultrasonic signal, the rate at which the capillaries replenish (refill with microbubbles) can be observed visually (qualitative assessment) or calculated using off-line software (quantitative assessment) . Blood flows through myocardial capillaries at 1mm/second and an ultrasound beam has an elevation width of 5mm, meaning that it takes about 5s for replenishment of the myocardium. A decrease in coronary blood flow will thus manifest as prolonged replenishment of microbubbles during destruction-replenishment imaging .Intuitively, tissue blood flow is determined by the amount of blood (capillary blood flow) and the speed at which it moves (red blood cell velocity). Therefore, myocardial blood flow (MBF) is calculated as:
Table 1: The accuracy of MCE for detection of coronary artery disease (CAD) (QL = Qualitative; QN = Quantitative; RT = Real-Time; TR = Triggered imaging; CI = Confidence Interval – from Senior et al )Additionally, a multi-centre, international phase III study of over 600 patients – with all image interpretation performed off site by independent readers – found MCE non-inferior to SPECT . Another recent study comparing adenosine MCE with adenosine CMR in 65 patients with suspected CAD undergoing angiography found a sensitivity of 85%, specificity of 76% and overall diagnostic accuracy of 82% for detection of CAD, which was comparable with adenosine CMR .
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