60 year old with coronary artery disease s/p PCI, HTN, dyslipidemia, smoking history and peripheral artery disease presenting for evaluation for ischemia. MEDICATIONS: aspirin, amlodipine, atorvastatin, carvedilol, hydrochlorothiazide First Pass PerfusionDuring hyperemia, there were perfusion defects present in the (1) apical anterior, septal, and inferior walls; (2) mid inferior, inferoseptal, anteroseptal, anterior, and anterolateral walls; (3) and in the basal anterior, anterolateral, inferior and inferoseptal walls.Viability/ Myocardial ScarThere are 3 distinct areas with late gadolinium enhancement. The first is a non-transmural myocardial infarction involving the basal to mid inferoseptum, this territory has an intermediate probability of viability. The second is a non-transmural myocardial infarction involving the mid to apical anterior wall, this territory has an intermediate probability viability. The third is a transmural patch of late gadolinium enhancement in the basal inferolateral wall. Because the late gadolinium enhancement is associated with hypertrophy rather than thinning, it is likely not due to a myocardial infarction and suggests the presence of an infiltrative or inflammatory process. This territory is also not likely to be viable. The remainder of the myocardium (which is a substantial amount of myocardium) is free of late gadolinium enhancement and likely to be viable. Left VentricleThe left ventricle is severely dilated with mildly reduced systolic function with moderate concentric left ventricular hypertrophy. The overall LV ejection fraction is 42%, the LV end diastolic volume index is 149 ml/m2 (normal range: 74+/-15), the LVEDV is 336 ml (normal range 142+/-34), the LV end systolic volume index is 87 ml/m2 (normal range 25+/-9), the LVESV is 195 ml (normal range 47+/-19), the LV mass index is 98 g/m2, and the LV mass is 222 g. There is global hypokinesis which is worst in the basal to mid inferior wall. Left AtriumThe left atrium is severely dilated. Right VentricleThe right ventricle is normal in size with mildly reduced systolic function. The overall RV ejection fraction is 48%, the RV end diastolic volume index is 66 ml/m2 (normal range 82+/-16), the RVEDV is 149 ml (normal range 142+/-31), the RV end systolic volume index is 34 ml/m2 (normal range 31+/-9), and the RVESV is 77 ml (normal range 54+/-17).Right AtriumThe right atrium is normal in size.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is mild mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThe aortic root is normal in size. There is a left sided aortic arch with a normal brachiocephalic branching pattern.Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is normal in size.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is no obvious pericardial disease.Extracardiac FindingsSmall (<1mm) axillary lymph nodes present. This study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.
1. There is an extensive amount of ischemia in a multi-vessel coronary distribution as described above. 2. There is an extensive amount of myocardial viability. Aside from the two above described non-transmural myocardial infarctions, much of the remainder of the myocardium is viable.3. There is an atypical pattern of late gadolinium enhancement involving the basal inferolateral wall suggesting the presence of a concomitant non-ischemic (possibly infiltrative or inflammatory) myocardial process.4. Severe LV dilation with mildly reduced systolic function (LVEF 42%) with global hypokinesis, most pronounced in the basal to mid inferior wall.5. Normal RV size with mildly reduced systolic function (RVEF 48%).6. Severe left atrial dilation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.