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[echocardiography] Re: mammary artery imaging?

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  • jamestam
    no but it does sound interesting. JT ... From: Daniel Shindler To: echocardiography@egroups.com Date:
    Message 1 of 4 , Mar 17, 1999
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      no
       
      but it does sound interesting.
       
      JT
      -----Original Message-----
      From: Daniel Shindler <shindler@...>
      To: echocardiography@egroups.com <echocardiography@egroups.com>
      Date: Wednesday, March 17, 1999 10:23 AM
      Subject: [echocardiography] mammary artery imaging?

      To the group: 
      Does anyone image mammary arteries on a regular basis?
      Dan Shindler
      
      
      
      
      Noninvasive functional assessment of left internal mammary artery grafts
      by transcutaneous Doppler echocardiography.
      
      Rombaut E; Vantrimpont P; Gurne O; Chenu P; Schroeder E; Buche M;
      Louagie Y; Eucher P; Marchandise B.
      
      J Am Soc Echocardiogr 1998 May;11(5):403-8
      
      A noninvasive method to assess left internal mammary artery (LIMA)
      patency and function would be useful because this vessel is frequently
      used for revascularization of the left anterior descending coronary
      artery.  The purpose of this study was to assess the feasibility of
      measuring changes in LIMA velocities by transcutaneous Doppler during
      dipyridamole-induced vasodilation.  Twenty-five patients with a LIMA
      graft anastomosed to the left anterior descending coronary artery were
      studied at least 1 month after surgery by the use of a 5 MHz transducer
      placed in the left supraclavicular fossa.   Doppler velocity parameters
      were measured at baseline and after intravenous administration of
      dipyridamole.   Dipyridamole increased mean velocity by 127% +/- 54% (p
      <0.001), systolodiastolic velocity time integral by 89% +/- 31%
      (p0.001), and diastolic-to-systolic peak velocity ration from 0.7 +/- to
      1.2 +- 0.4 (p <0.001).   The dipyridamole-to-baseline mean velocity
      ration was 2.3 +/- 0.5.    We conclude that it is possible to measure
      dipyridamole-induced changes in LIMA blood velocity reserve by
      transcutaneous Doppler echocardiography.
      
      
      Internal mammary artery: 100% visualization with new ultrasound
      technology.
      
      Ehrsam JE; Spittell PC; Seward JB
      
      J Am Soc Echocardiogr 1998 Jan;11(1):10-2
      
      We report our experience in visualizing the internal mammary artery
      (IMA) with new enhanced Doppler technology.   Twenty-three patients
      without previous coronary artery bypass grafting formed the study
      group.  Bilateral transthoracic two-dimensional and color flow Doppler
      IMA images were acquired from multiple intercostal spaces with a
      prototype ultrasound machine equipped with coherent beam formation
      technology.   In all patients, the IMA was followed from its origin for
      an average of  15 cm.   To our knowledge, a high rate of direct
      visualization (100%) of the IMA has not been reported previously. 
      Noninvasive ultrasound assessment of the IMA may reduce the need for
      invasive preoperative testing for patency and length and allow
      postoperative assessment of coronary artery flow reserve.
      
      
      
      Noninvasive assessment of left internal mammary artery graft patency
      using transthoracic echocardiography [see comments]
      
      Crowley JJ; Shapiro LM
      
      Circulation 1995 Nov 1;92 (9 Suppl):II25-30
      
      BACKGROUND:  Cardiac catheterization is the only practical method of
      assessing internal mammary artery graft patency.   A noninvasive method
      would be useful in patients with recurrence of anginal symptoms after
      coronary artery bypass graft surgery.   We hypothesized that
      transthoracic echocardiography could provide information on blood
      velocity and anatomy and therefore has the potential to allow
      measurement of blood flow.   METHODS AND RESULTS: High-frequency (5 MHz)
      transthoracic echocardiography was performed on 41 consecutive patients
      (mean age, 67 +/- 6 years) who had had left internal mammary artery
      grafts to the left anterior descending coronary artery (LAD and were
      undergoing coronary angiography because of recurrence of anginal
      symptoms.   The results were compared with those from 19 patients (mean
      age, 58 +/- 11 years) in whom an ungrafted left internal mammary artery
      was assessed and with those from 15 patients (mean age, 61 +/- 12 years)
      who had angiographically normal coronary arteries in whom the LAD was
      studied.   Doppler velocity profiles of the left internal mammary graft
      were obtained in 35 of the 41 study patients (81%).   In all cases, a
      biphasic pattern of blood flow was recorded that corresponded to systole
      and diastole.   Two different flow patterns were observed.  In 25
      patients with a normal graft or moderate (<70%) stenosis (group A),
      blood flow velocity was maximal during diastole.   This pattern was also
      seen in the LAD control group.   In 10 patients with severe (>70%) graft
      stenosis (group B), blood velocity was maximal during systole, and low
      velocities were recorded during diastole.   This pattern was also seen
      in the ungrafted internal mammary artery control group.    The diastolic
      fraction of the velocity time integrals for group A was 0.77 +/- 0.07
      and for group B was 0.27 +/- 0.01 (P <. 05).   A diastolic velocity time
      integral fraction < predicted severe stenosis with a sensitivity and
      specificity of 100%.   The ration of systolic-to-diastolic peak
      velocities for group was 0.54 +/- 0.26 and for group B was 3.45 +/- 0.74
      (P <.05).  A systolic-to-diastolic peak velocity ration > 1 predicted
      severe stenosis with a sensitivity of 100% and specificity of 85%.  
      Mean graft blood flow was 63 +/- 21 mL/min.   There was no significant
      difference in mean blood flow between any of the patient groups
      studied.  CONCLUSION:  High-frequency transthoracic echocardiography
      allows identification of the left internal mammary grafts and
      measurement of blood flow.   Compared with patent grafts or those with
      moderate lesions, severe stenoses demonstrated different Doppler
      velocity patterns.   Use of this technique may allow noninvasive
      detection of significant stenoses of the left internal mammary artery
      graft.
      
      
      Noninvasive assessment of left internal mammary artery graft patency
      using duplex Doppler echocardiography from supraclavicular fossa.
      
      Takagi T; Yoshikawa J; Yosida K; Akasaka T.
      
      J Am Coll Cardiol 1993 Nov 15;22(6):1647-52
      
      OBJECTIVES:   The purpose of this study was to clarify the usefulness of
      duplex Doppler echocardiography from the supraclavicular fossa for
      assessment of left internal mammary artery graft patency.   BACKGROUND: 
      A noninvasive method to assess coronary artery bypass graft patency
      would be useful for assess coronary artery bypass graft patency would be
      useful for clinical diagnosis and long-term follow-up of graft
      outcome.   METHODS:  Duplex Doppler echocardiography from the
      supraclavicular fossa was performed in 56 consecutive patients who
      underwent postoperative cardiac catheterization studies, including
      quantitative angiography.   All patients underwent coronary artery
      bypass graft surgery using the left internal mammary artery graft to the
      left anterior descending coronary artery.   RESULTS:  The left internal
      mammary artery graft and its flow were detected in 55 (98%) of the 56
      patients with duplex Doppler echocardiography from the supraclavicular
      fossa.   According to the quantitative angiographic data, the patients
      wee assigned to three groups: group A (36 patients) with a normal left
      internal mammary artery graft (<50% diameter stenosis), group B (9
      patients) with intermediate (50% to 75% diameter) graft stenosis and
      group C (10 patients) with severe (> 75% diameter) graft stenosis.   The
      diastolic/systolic peak velocity ration was smaller in group C than in
      groups A and B (p < 0.05), but there was no significant difference
      between groups A and B.    A diastolic/systolic peak velocity ration <
      0.6 predicted severe left internal mammary artery graft stenosis (> 75%
      diameter stenosis) with a sensitivity and specificity of 100% and 80%,
      respectively.   The diastolic fraction of time-velocity integral was
      smaller in group C than in groups A and B (p < 0.05), but there was no
      significant difference between groups A and B.   A diastolic fraction
      <0.5 predicted significant left internal mammary artery graft stenosis
      755% diameter stenosis) with a sensitivity and specificity of 90% and
      100%, respectively.   CONCLUSIONS:  Duplex Doppler echocardiography from
      the supraclavicular fossa is useful for noninvasive assessment of left
      internal mammary artery graft patency.


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    • Daniel Shindler
      To the group: Does anyone image mammary arteries on a regular basis? Dan Shindler Noninvasive functional assessment of left internal mammary artery grafts by
      Message 2 of 4 , Mar 17, 1999
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        To the group:
        Does anyone image mammary arteries on a regular basis?
        Dan Shindler




        Noninvasive functional assessment of left internal mammary artery grafts
        by transcutaneous Doppler echocardiography.

        Rombaut E; Vantrimpont P; Gurne O; Chenu P; Schroeder E; Buche M;
        Louagie Y; Eucher P; Marchandise B.

        J Am Soc Echocardiogr 1998 May;11(5):403-8

        A noninvasive method to assess left internal mammary artery (LIMA)
        patency and function would be useful because this vessel is frequently
        used for revascularization of the left anterior descending coronary
        artery. The purpose of this study was to assess the feasibility of
        measuring changes in LIMA velocities by transcutaneous Doppler during
        dipyridamole-induced vasodilation. Twenty-five patients with a LIMA
        graft anastomosed to the left anterior descending coronary artery were
        studied at least 1 month after surgery by the use of a 5 MHz transducer
        placed in the left supraclavicular fossa. Doppler velocity parameters
        were measured at baseline and after intravenous administration of
        dipyridamole. Dipyridamole increased mean velocity by 127% +/- 54% (p
        <0.001), systolodiastolic velocity time integral by 89% +/- 31%
        (p0.001), and diastolic-to-systolic peak velocity ration from 0.7 +/- to
        1.2 +- 0.4 (p <0.001). The dipyridamole-to-baseline mean velocity
        ration was 2.3 +/- 0.5. We conclude that it is possible to measure
        dipyridamole-induced changes in LIMA blood velocity reserve by
        transcutaneous Doppler echocardiography.


        Internal mammary artery: 100% visualization with new ultrasound
        technology.

        Ehrsam JE; Spittell PC; Seward JB

        J Am Soc Echocardiogr 1998 Jan;11(1):10-2

        We report our experience in visualizing the internal mammary artery
        (IMA) with new enhanced Doppler technology. Twenty-three patients
        without previous coronary artery bypass grafting formed the study
        group. Bilateral transthoracic two-dimensional and color flow Doppler
        IMA images were acquired from multiple intercostal spaces with a
        prototype ultrasound machine equipped with coherent beam formation
        technology. In all patients, the IMA was followed from its origin for
        an average of 15 cm. To our knowledge, a high rate of direct
        visualization (100%) of the IMA has not been reported previously.
        Noninvasive ultrasound assessment of the IMA may reduce the need for
        invasive preoperative testing for patency and length and allow
        postoperative assessment of coronary artery flow reserve.



        Noninvasive assessment of left internal mammary artery graft patency
        using transthoracic echocardiography [see comments]

        Crowley JJ; Shapiro LM

        Circulation 1995 Nov 1;92 (9 Suppl):II25-30

        BACKGROUND: Cardiac catheterization is the only practical method of
        assessing internal mammary artery graft patency. A noninvasive method
        would be useful in patients with recurrence of anginal symptoms after
        coronary artery bypass graft surgery. We hypothesized that
        transthoracic echocardiography could provide information on blood
        velocity and anatomy and therefore has the potential to allow
        measurement of blood flow. METHODS AND RESULTS: High-frequency (5 MHz)
        transthoracic echocardiography was performed on 41 consecutive patients
        (mean age, 67 +/- 6 years) who had had left internal mammary artery
        grafts to the left anterior descending coronary artery (LAD and were
        undergoing coronary angiography because of recurrence of anginal
        symptoms. The results were compared with those from 19 patients (mean
        age, 58 +/- 11 years) in whom an ungrafted left internal mammary artery
        was assessed and with those from 15 patients (mean age, 61 +/- 12 years)
        who had angiographically normal coronary arteries in whom the LAD was
        studied. Doppler velocity profiles of the left internal mammary graft
        were obtained in 35 of the 41 study patients (81%). In all cases, a
        biphasic pattern of blood flow was recorded that corresponded to systole
        and diastole. Two different flow patterns were observed. In 25
        patients with a normal graft or moderate (<70%) stenosis (group A),
        blood flow velocity was maximal during diastole. This pattern was also
        seen in the LAD control group. In 10 patients with severe (>70%) graft
        stenosis (group B), blood velocity was maximal during systole, and low
        velocities were recorded during diastole. This pattern was also seen
        in the ungrafted internal mammary artery control group. The diastolic
        fraction of the velocity time integrals for group A was 0.77 +/- 0.07
        and for group B was 0.27 +/- 0.01 (P <. 05). A diastolic velocity time
        integral fraction < predicted severe stenosis with a sensitivity and
        specificity of 100%. The ration of systolic-to-diastolic peak
        velocities for group was 0.54 +/- 0.26 and for group B was 3.45 +/- 0.74
        (P <.05). A systolic-to-diastolic peak velocity ration > 1 predicted
        severe stenosis with a sensitivity of 100% and specificity of 85%.
        Mean graft blood flow was 63 +/- 21 mL/min. There was no significant
        difference in mean blood flow between any of the patient groups
        studied. CONCLUSION: High-frequency transthoracic echocardiography
        allows identification of the left internal mammary grafts and
        measurement of blood flow. Compared with patent grafts or those with
        moderate lesions, severe stenoses demonstrated different Doppler
        velocity patterns. Use of this technique may allow noninvasive
        detection of significant stenoses of the left internal mammary artery
        graft.


        Noninvasive assessment of left internal mammary artery graft patency
        using duplex Doppler echocardiography from supraclavicular fossa.

        Takagi T; Yoshikawa J; Yosida K; Akasaka T.

        J Am Coll Cardiol 1993 Nov 15;22(6):1647-52

        OBJECTIVES: The purpose of this study was to clarify the usefulness of
        duplex Doppler echocardiography from the supraclavicular fossa for
        assessment of left internal mammary artery graft patency. BACKGROUND:
        A noninvasive method to assess coronary artery bypass graft patency
        would be useful for assess coronary artery bypass graft patency would be
        useful for clinical diagnosis and long-term follow-up of graft
        outcome. METHODS: Duplex Doppler echocardiography from the
        supraclavicular fossa was performed in 56 consecutive patients who
        underwent postoperative cardiac catheterization studies, including
        quantitative angiography. All patients underwent coronary artery
        bypass graft surgery using the left internal mammary artery graft to the
        left anterior descending coronary artery. RESULTS: The left internal
        mammary artery graft and its flow were detected in 55 (98%) of the 56
        patients with duplex Doppler echocardiography from the supraclavicular
        fossa. According to the quantitative angiographic data, the patients
        wee assigned to three groups: group A (36 patients) with a normal left
        internal mammary artery graft (<50% diameter stenosis), group B (9
        patients) with intermediate (50% to 75% diameter) graft stenosis and
        group C (10 patients) with severe (> 75% diameter) graft stenosis. The
        diastolic/systolic peak velocity ration was smaller in group C than in
        groups A and B (p < 0.05), but there was no significant difference
        between groups A and B. A diastolic/systolic peak velocity ration <
        0.6 predicted severe left internal mammary artery graft stenosis (> 75%
        diameter stenosis) with a sensitivity and specificity of 100% and 80%,
        respectively. The diastolic fraction of time-velocity integral was
        smaller in group C than in groups A and B (p < 0.05), but there was no
        significant difference between groups A and B. A diastolic fraction
        <0.5 predicted significant left internal mammary artery graft stenosis
        755% diameter stenosis) with a sensitivity and specificity of 90% and
        100%, respectively. CONCLUSIONS: Duplex Doppler echocardiography from
        the supraclavicular fossa is useful for noninvasive assessment of left
        internal mammary artery graft patency.

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      • Aristiliano Ramos Neto
        I don t, but I agree that it is interesting and I will try to do it. Aristiliano Ramos Neto ... From: Daniel Shindler To:
        Message 3 of 4 , Mar 17, 1999
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          I don't, but I agree that it is interesting and I will try to do it.
          Aristiliano Ramos Neto
          -----Original Message-----
          From: Daniel Shindler <shindler@...>
          To: echocardiography@egroups.com <echocardiography@egroups.com>
          Date: Quarta-feira, 17 de Março de 1999 13:18
          Subject: [echocardiography] mammary artery imaging?


          >To the group:
          >Does anyone image mammary arteries on a regular basis?
          >Dan Shindler
          >
          >
          >
          >
          >Noninvasive functional assessment of left internal mammary artery grafts
          >by transcutaneous Doppler echocardiography.
          >
          >Rombaut E; Vantrimpont P; Gurne O; Chenu P; Schroeder E; Buche M;
          >Louagie Y; Eucher P; Marchandise B.
          >
          >J Am Soc Echocardiogr 1998 May;11(5):403-8
          >
          >A noninvasive method to assess left internal mammary artery (LIMA)
          >patency and function would be useful because this vessel is frequently
          >used for revascularization of the left anterior descending coronary
          >artery. The purpose of this study was to assess the feasibility of
          >measuring changes in LIMA velocities by transcutaneous Doppler during
          >dipyridamole-induced vasodilation. Twenty-five patients with a LIMA
          >graft anastomosed to the left anterior descending coronary artery were
          >studied at least 1 month after surgery by the use of a 5 MHz transducer
          >placed in the left supraclavicular fossa. Doppler velocity parameters
          >were measured at baseline and after intravenous administration of
          >dipyridamole. Dipyridamole increased mean velocity by 127% +/- 54% (p
          ><0.001), systolodiastolic velocity time integral by 89% +/- 31%
          >(p0.001), and diastolic-to-systolic peak velocity ration from 0.7 +/- to
          >1.2 +- 0.4 (p <0.001). The dipyridamole-to-baseline mean velocity
          >ration was 2.3 +/- 0.5. We conclude that it is possible to measure
          >dipyridamole-induced changes in LIMA blood velocity reserve by
          >transcutaneous Doppler echocardiography.
          >
          >
          >Internal mammary artery: 100% visualization with new ultrasound
          >technology.
          >
          >Ehrsam JE; Spittell PC; Seward JB
          >
          >J Am Soc Echocardiogr 1998 Jan;11(1):10-2
          >
          >We report our experience in visualizing the internal mammary artery
          >(IMA) with new enhanced Doppler technology. Twenty-three patients
          >without previous coronary artery bypass grafting formed the study
          >group. Bilateral transthoracic two-dimensional and color flow Doppler
          >IMA images were acquired from multiple intercostal spaces with a
          >prototype ultrasound machine equipped with coherent beam formation
          >technology. In all patients, the IMA was followed from its origin for
          >an average of 15 cm. To our knowledge, a high rate of direct
          >visualization (100%) of the IMA has not been reported previously.
          >Noninvasive ultrasound assessment of the IMA may reduce the need for
          >invasive preoperative testing for patency and length and allow
          >postoperative assessment of coronary artery flow reserve.
          >
          >
          >
          >Noninvasive assessment of left internal mammary artery graft patency
          >using transthoracic echocardiography [see comments]
          >
          >Crowley JJ; Shapiro LM
          >
          >Circulation 1995 Nov 1;92 (9 Suppl):II25-30
          >
          >BACKGROUND: Cardiac catheterization is the only practical method of
          >assessing internal mammary artery graft patency. A noninvasive method
          >would be useful in patients with recurrence of anginal symptoms after
          >coronary artery bypass graft surgery. We hypothesized that
          >transthoracic echocardiography could provide information on blood
          >velocity and anatomy and therefore has the potential to allow
          >measurement of blood flow. METHODS AND RESULTS: High-frequency (5 MHz)
          >transthoracic echocardiography was performed on 41 consecutive patients
          >(mean age, 67 +/- 6 years) who had had left internal mammary artery
          >grafts to the left anterior descending coronary artery (LAD and were
          >undergoing coronary angiography because of recurrence of anginal
          >symptoms. The results were compared with those from 19 patients (mean
          >age, 58 +/- 11 years) in whom an ungrafted left internal mammary artery
          >was assessed and with those from 15 patients (mean age, 61 +/- 12 years)
          >who had angiographically normal coronary arteries in whom the LAD was
          >studied. Doppler velocity profiles of the left internal mammary graft
          >were obtained in 35 of the 41 study patients (81%). In all cases, a
          >biphasic pattern of blood flow was recorded that corresponded to systole
          >and diastole. Two different flow patterns were observed. In 25
          >patients with a normal graft or moderate (<70%) stenosis (group A),
          >blood flow velocity was maximal during diastole. This pattern was also
          >seen in the LAD control group. In 10 patients with severe (>70%) graft
          >stenosis (group B), blood velocity was maximal during systole, and low
          >velocities were recorded during diastole. This pattern was also seen
          >in the ungrafted internal mammary artery control group. The diastolic
          >fraction of the velocity time integrals for group A was 0.77 +/- 0.07
          >and for group B was 0.27 +/- 0.01 (P <. 05). A diastolic velocity time
          >integral fraction < predicted severe stenosis with a sensitivity and
          >specificity of 100%. The ration of systolic-to-diastolic peak
          >velocities for group was 0.54 +/- 0.26 and for group B was 3.45 +/- 0.74
          >(P <.05). A systolic-to-diastolic peak velocity ration > 1 predicted
          >severe stenosis with a sensitivity of 100% and specificity of 85%.
          >Mean graft blood flow was 63 +/- 21 mL/min. There was no significant
          >difference in mean blood flow between any of the patient groups
          >studied. CONCLUSION: High-frequency transthoracic echocardiography
          >allows identification of the left internal mammary grafts and
          >measurement of blood flow. Compared with patent grafts or those with
          >moderate lesions, severe stenoses demonstrated different Doppler
          >velocity patterns. Use of this technique may allow noninvasive
          >detection of significant stenoses of the left internal mammary artery
          >graft.
          >
          >
          >Noninvasive assessment of left internal mammary artery graft patency
          >using duplex Doppler echocardiography from supraclavicular fossa.
          >
          >Takagi T; Yoshikawa J; Yosida K; Akasaka T.
          >
          >J Am Coll Cardiol 1993 Nov 15;22(6):1647-52
          >
          >OBJECTIVES: The purpose of this study was to clarify the usefulness of
          >duplex Doppler echocardiography from the supraclavicular fossa for
          >assessment of left internal mammary artery graft patency. BACKGROUND:
          >A noninvasive method to assess coronary artery bypass graft patency
          >would be useful for assess coronary artery bypass graft patency would be
          >useful for clinical diagnosis and long-term follow-up of graft
          >outcome. METHODS: Duplex Doppler echocardiography from the
          >supraclavicular fossa was performed in 56 consecutive patients who
          >underwent postoperative cardiac catheterization studies, including
          >quantitative angiography. All patients underwent coronary artery
          >bypass graft surgery using the left internal mammary artery graft to the
          >left anterior descending coronary artery. RESULTS: The left internal
          >mammary artery graft and its flow were detected in 55 (98%) of the 56
          >patients with duplex Doppler echocardiography from the supraclavicular
          >fossa. According to the quantitative angiographic data, the patients
          >wee assigned to three groups: group A (36 patients) with a normal left
          >internal mammary artery graft (<50% diameter stenosis), group B (9
          >patients) with intermediate (50% to 75% diameter) graft stenosis and
          >group C (10 patients) with severe (> 75% diameter) graft stenosis. The
          >diastolic/systolic peak velocity ration was smaller in group C than in
          >groups A and B (p < 0.05), but there was no significant difference
          >between groups A and B. A diastolic/systolic peak velocity ration <
          >0.6 predicted severe left internal mammary artery graft stenosis (> 75%
          >diameter stenosis) with a sensitivity and specificity of 100% and 80%,
          >respectively. The diastolic fraction of time-velocity integral was
          >smaller in group C than in groups A and B (p < 0.05), but there was no
          >significant difference between groups A and B. A diastolic fraction
          ><0.5 predicted significant left internal mammary artery graft stenosis
          >755% diameter stenosis) with a sensitivity and specificity of 90% and
          >100%, respectively. CONCLUSIONS: Duplex Doppler echocardiography from
          >the supraclavicular fossa is useful for noninvasive assessment of left
          >internal mammary artery graft patency.
          >
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          >
          >
          >


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        • kitpowers@pol.net
          Sounds very interesting--we have been using Acuson Sequoias, and I d like to give it a try with these machines...? would contrast help? Also of interest is a
          Message 4 of 4 , Mar 19, 1999
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            Sounds very interesting--we have been using Acuson Sequoias, and I'd like to give it a try with these machines...? would contrast help?

            Also of interest is a study from Circ 99:pp771 (Caiati, et al) re: assessment of LAD flow reserve with similar technique (dipyridamole enhanced flow) and suggests vessel patency or serious stenosis could be diagnosed from this non-invasive technique. They did use contrast to augment imaging.

            Anyone interested in collaborating in a validation study comparing stress echo, cath and LIMA or LAD imaging?

            Kit Bjella Powers


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