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Purpose: The aim of this study was to evaluate the feasibility of myocardial wall-motion and perfusion assessment using contrast echocardiography during real-time three-dimensional (RT3D) adenosine stress test, and compare its diagnostic accuracy with the two-dimensional (2D) method using coronary angiography as reference.Methods: Patients with known or suspected coronary artery disease (CAD) have been submitted to adenosine stress contrast echocardiography and coronary angiography, within a one month-period. 2D apical four-, two- and three- chamber, as well as three-dimensional (3D) pyramidal full-volume datasets were acquired at rest and at peak stress. The 17-segment division of the left ventricle was used and each segment was evaluated based on wall motion and perfusion.Results: Sixty patients (age 60.1±8.5 years, 38 men) were enrolled, i.e. 1020 segments were evaluated at rest and at peak stress. Out of the 1020 segments, wall motion analysis was feasible, at rest, in 98% and in 97% of 2D and 3D depicted segments respectively (p=NS). The respective evaluated segments at peak stress were 93% for 2D and 92% for 3D. Perfusion could be evaluated, at rest, in 97% and in 96% of 2D and 3D depicted segments, respectively (p=NS). At peak stress the evaluated percentages were 92% for 2D and 90% for 3D. Wall motion analysis per patient revealed that the sensitivity and specificity of 2D to detect CAD were 80% and 82% and of RT3D echocardiography were 82% and 64%, respectively, while in the per patient perfusion analysis the respective percentages were 88%, 64% for 2D, and 90%, 73% for RT3D. Regarding left anterior descending artery and right coronary system, there seems to be no statistical significant difference in terms of wall motion and perfusion evaluation between the two modalities.Conclusions: Real-time 3D adenosine stress echocardiography is a feasible and valuable technique to evaluate myocardial wall-motion and perfusion in patients with suspected coronary artery disease, despite existing problems concerning lower spatial and temporal resolution as compared with 2D echocardiography.