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Myocardial blush: Can we measure it?

Antegrade coronary flow restoration is currently an unquestionable keystone in the treatment of patients with ST-elevation acute myocardial infarction. Researchers have soon realized that achieving a brisk flow of the culprit vessel at angiography (i.e., TIMI flow II or III) was not sufficient, as a marker, to guarantee that myocardial blood flow was fully reestablished in acute myocardial infarction. Instead, on top of good flow at the epicardial compartment, adequate restoration of microcirculatory circulation was also central in decreasing infarct size and, ultimately, decreasing mortality. A number of methods have been suggested to assess the efficacy of reperfusion in acute myocardial infarction. The so-called myocardial blush has gained much attention over the last years due to its proven prognostic value and its simplicity—it is an angiographic index, readily applicable to virtually any patient undergoing primary angioplasty. However, especially for coronary branches of the left coronary system, practice has taught that blush assessment is not always easily assessable, mainly due to vessel overlapping and to the subtleness involved in the visual examination of myocardial opacification. Accordingly, previous surveys have shown a somewhat limited intraand interobserver variability of blush assessment. In this issue of CCI, Haeck and coworkers present a method to numerically quantify the angiographic myocardial blush. The authors were able to show that the new method is significantly associated with ST-segment resolution after PCI and with the postinfarction peak CKMB values. Unfortunately, no objective data is presented on the variability and reproducibility of the new method. Also, their study does not provide a direct comparison between the new computer-based approach with the ‘‘traditional’’ visual semi-quantification of myocardial blush, in terms of their ability to predict ST-segment restoration and enzymatic release. It would be desirable for the new method to prove an at least similar predictive value, together with lower variability and improved reproducibility. Haeck and coworkers used an open-source software (The Quantitative Blush Evaluation—QuBE, available at http://QuBE.sf.net; the source code is downloadable from http://sourceforge.net/projects/qube/) for their analysis. The free availability of the software and its source code lands at the opposite corner from most computerized tools dedicated to angiographic analysis of coronary parameters, which are frequently locked, copyright-protected, expensive softwares. It is important to note that while open-source programs provide the means for a more widespread and democratic use, they do not require obligatory compliance with international standards, such as Management System and Software Development Process certifications, as well as the approval of medical devices regulatory agencies. Anyway, the development of open-source softwares, such as the Quantitative Blush Evaluation tested in the present study, may be seen as a welcomed novelty with the potential to help improving the overall field of cardiovascular imaging.