To evaluate myocardial tissue changes using two-dimensional (2D) echocardiography, several approaches were attempted. 1. Quantitative evaluation of the myocardial echo intensity by computerized image processing in patients with old anteroseptal myocardial infarction: 2D echocardiograms of the parasternal long-axis view were converted to digital images to measure the echo intensity of the regions of interest (ROI) placed in the interventricular septum (IVS), the left ventricular posterior wall (LVPW), the left ventricular cavity, and the pericardium. The mean value of the echo intensity was compared with that of the pericardium (maximum echo intensity) and of the left ventricular cavity as the minimum. In 12 normal subjects, the relative echo intensity of the IVS was 0.40 +/- 0.05 (mean +/- SE), whereas it was 0.71 +/- 0.06 in 11 patients with old MI (p less than 0.001). Color display facilitated the visual recognition of the numerical differences in echo intensities. 2. Evaluation of the myocardial echo intensity in acute phase of myocardial infarction: In nine normal elderly persons, the relative echo intensity of IVS was 0.29 +/- 0.14, and there was no significant change in the early stage (three to seven days) of acute infarction (0.31 +/- 0.14). Two weeks later, however, a significant increase was noted (0.61 +/- 0.10) (p less than 0.01), probably due to an increase in collagen fibers. 3. Changes of the myocardial echo intensity in acute myocardial ischemia: Two-dimensional echocardiograms were recorded in nine open-chest dogs using 3 and 5 MHz transducers before and 10 min, 1 hr, 3 hrs, and 6 hrs after coronary artery ligation. With the 5 MHz transducer, the echo intensity of the ischemic myocardium was decreased after 10 min and was remarkable after 1 hr (0.24 +/- 0.08), and restored in six hrs. These changes could not be detected using the 3 MHz transducer. 4. An in vitro study for assessment of ultrasonic attenuation in the canine infarcted myocardium: The frequency dependency of ultrasonic attenuation of the resected canine myocardium in the frequency region of 2 MHz to 7 MHz was estimated one and two weeks after coronary artery ligation. The distributions of attenuation characteristics were nearly consistent with those of collagen contents determined histologically. In conclusion, we demonstrated that acute and chronic ischemia of the myocardium influences the transmission and reflection of ultrasound. By applying this property, ultrasonic tissue characterization may become a useful tool for detecting myocardial ischemia in the near future.