**5. Summary and look to the future**

Thus, transthoracic Doppler echocardiography is feasible and provides important information about the function of coronary microcirculation in patients with acute STEMI undergoing PPCI. Treatment with eptifibatide before primary angioplasty, prevented early LAD systolic flow reversal indicative of severe dysfunction of the microcirculation, increased diastolic LAD velocities and flows but did not increase left ventricular systolic function. Understanding mechanisms of dysfunction of the coronary microcirculation and implementation of newer strategies to treat microcirculatory dysfunction with transthoracic Doppler evaluation may improve the treatment of patients with acute STEMI undergoing primary angioplasty.

#### **6. References**

70 Echocardiography – In Specific Diseases

squared to calculate areas. Thus if blood velocities, and colour jet diameters of the LAD are similar to those of cardiac valves, then flow calculations should be of the same degree of

Restoration of epicardial coronary artery flow by primary PCI in the setting of acute STEMI improves outcome (Shah et al, 2000), however optimization of myocardial tissue perfusion improves the prediction of outcome (van't Hof et al, 1998; Shah et al, 2000; van't Hof et al, 1997; Claeys et al, 1999; The TIMI Study Group, 19985; Gibson et al, 1996; 1999; 2001; de Lemos, 2001; Dörge et al, 2000). Despite these findings, still even with successful primary PCI and the high rate of patency of the culprit artery, left ventricular functional recovery is

 Despite the value of myocardial blush grade in the evaluation of myocardial perfusion it is not repeatable because of its invasive nature. Resolution of ST-elevation also correlates with better myocardial perfusion, however it reflects only the stage immediately following the emergency PCI. As we have shown (Sharif et al, 2008) the function of coronary microcirculation is variable and may improve or worsen during the hospital stay after primary coronary angioplasty in patients with acute STEMI. Therefore, Doppler

To understand the relation between DDT and coronary microcirculation, consider normal subjects where the intra-myocardial blood capacitance vessels fill during diastole without significant increase in intramural pressure, therefore the DDT is prolonged. When the capacitance vessels are partially obstructed with miroemboli there is impedance to flow in diastole, therefore the DDT is abbreviated (Kawamoto et al, 1999; Yamamaro et al, 2002). When the blockage of the microcirculation is more severe, the milking of blood in systole cannot proceed to the venules; instead, it is pushed back into the coronary artery and results

**4.7 Mechanisms of dysfunction of coronary microcirculation after primary coronary** 

After primary PCI, dysfunction of the microcirculation may develop as a result of periprocedural microembolization to the distal coronary artery bed. In addition, recently, evidence for the hypothesis that in situ inflammation and thrombosis contributes to dysfunction of the microcirculation after primary PCI was provided (Dörge et al, 2000). Despite the tendency of microemboli to dissolve after they developed during primary PCI, in situ microcirculatory thrombosis may account for worsening of microcirculatory function late after primary PCI. Thus not only early evaluation of the coronary microcirculation is important; in fact the worst coronary microcirculatory status like minimal diastolic deceleration time of LAD blood velocity seems to be even more

**4.5 Need for coronary blood velocity sampling in acute STEMI** 

limited and not well predicted (Stone et al, 1997; Zijlstra et al, 1997).

transthorcaic sampling of LAD blood velocities is important in such patients.

**4.6 Diastolic deceleration time of LAD blood velocity curve (DDT) and the** 

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**6** 

*Japan* 

**Pulmonary Venous Flow Pattern and Atrial** 

Mitsuhiro Fukata2, Shioto Yasuda2, Keita Odashiro2 and Koichi Akashi2

The role of echocardiography in patients with atrial fibrillation (AF) has been changing gradually according with recent advance in echocardiographic instruments and better understanding for AF. Historically, M-mode echocardiography applied to AF patients has focused on the diagnosis of underlying organic heart diseases and on the detection of left atrial (LA) thrombi. These are not surprising because AF had been the highest risk of ischemic stroke in the era of incomplete anticoagulation therapy. Thereafter, LA size, volume and functions have been foci assessed by echocardiography. These echocardiographic procedures have been conducted for prediction and prevention of recurrence of AF paroxysms (Barbier et al, 1994; Verdecchia et al, 2003; Vasan et al, 2003). Spontaneous echo contrast has also been an established B-mode echocardiographic finding with highly predictive value of ischemic stroke. After the development of Doppler echocardiography, pulmonary venous flow (PVF) evaluation is a routine laboratory investigation for patients with and without AF. The usefulness of PVF evaluation is not limited to assess LA or left ventricular (LV) functions, but has expanded to investigation of various aspects of AF (Tabata et al., 2003). PVF recording increases its usefulness when it is combined with recordings of Doppler LV inflow pattern. This article reviews the established usefulness of PVF estimation in patients with permanent AF, and then focuses on the potential usefulness of PVF assessment in AF progression, i.e., during sinus rhythm (i.e., interval of paroxysms of AF), during ongoing paroxysmal AF, and further during the long-

AF is one of the most common sustained arrhythmias in daily clinical practice. There has been a great advance in the exploration of the etiologies of AF. These are the subject of several overlapping schemes of individual pathogenesis, i.e., atrial overload and stretch, myocardial ischemia and inflammation, degeneration and subsequent fibrosis of atrial myocardium, neurohumoral or metabolic factors, and other unknown factors. Therefore, clinical presentations of AF are very broad. This arrhythmia occurs in a variety of clinical

**1. Introduction** 

term AF management.

**2. Clinical Perspectives of AF** 

**Fibrillation: Fact and Controversy** 

*2Department of Medicine, Kyushu University, Fukuoka* 

*1Institute of Health Science and* 

Toru Maruyama1, Yousuke Kokawa2, Hisataka Nakamura2,

