65 year old man with history of cirrhosis, paroxysmal atrial fibrillation, CAD s/p CABG in February 2015 (LIMA to LAD, VG to PDA and VG to OM1) with new LV dysfunction noted on echocardiography. He was referred for cardiac stress MR to evaluate for ischemia and viability.MEDICATIONS: atorvastatin, coumadin, dofetilide, metoprolol, nifedipine, fish oil, diovan, nitroglycerin as needed First Pass PerfusionDuring hyperemia, there was a moderate to severe defect in the basal, mid and apical inferoseptum and a moderate defect in the mid inferior wall. The inferoseptal defect was present at rest and appeared mild. Viability/ Myocardial ScarThere was no late gadolinium enhancement noted suggesting that there is no prior myocardial infarction, fibrosis, inflammation, or infiltration. The entire myocardium is viable. Left VentricleThe left ventricle is normal in size with mildly reduced systolic function. The overall LV ejection fraction is 54%, the LV end diastolic volume index is 95 ml/m2 (normal range: 74+/-15), the LVEDV is 180 ml (normal range 142+/-34), the LV end systolic volume index is 43 ml/m2 (normal range 25+/-9), the LVESV is 82 ml (normal range 47+/-19), the LV mass index is 43 g/m2, and the LV mass is 82 g. There is abnormal septal motion consistent with the history of LBBB conduction abnormality and previous surgery. There is also tardokinesis of the mid-distal inferior wall. Left AtriumThe left atrium is severely dilated. Right VentricleThe right ventricle is normal in size with normal systolic function. . The overall RV ejection fraction is 51%, the RV end diastolic volume index is 103 ml/m2 (normal range 82+/-16), the RVEDV is 195 ml (normal range 142+/-31), the RV end systolic volume index is 50 ml/m2 (normal range 31+/-9), and the RVESV is 96 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. There is mild thickening of the valve leaflets. There is at least mild-moderate mitral regurgitation noted.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is at least mild tricuspid regurgitation, which appears eccentric.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 FindingsSternotomy wires are present. There is nonspecific esophageal thickening. Cirrhosis again noted. No gross hepatic lesion of the study was not optimized for such an evaluation. 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. At rest there was a mild defect in the inferoseptum which worsened with stress to a moderate to severe perfusion defect in the basal, mid and apical inferoseptum. With hyperemia, there was also a moderate perfusion defect in the mid inferior wall. 2. No prior myocardial infarction. The entire myocardium is viable.3. Normal LV size and mildly reduced systolic function (LVEF 54%).4. Normal RV size and systolic function (RVEF 51%).5. At least mild-moderate mitral regurgitation.6. At least mild tricuspid regurgitation.7. Severe left atrial dilation. 