A 73 year old male with personal history of liver transplant, hyperlipidemia, peripheral artery disease. His cardiovascular history includes coronary artery disease with a percutaneous stent implantation in 2010 and a aortic valvular replacement (robotic approach) in 11/2015 (a coronary angiography previous to the surgery showed patents LAD stent, 50% stenosis in ostial 3rd diagonal and mild disease in the LCx and RCA). Recently reported angina of effort with ST depressions in the EKG during exercise. Referred to stress cardiac MRI for further evaluationMEDICATIONS: aspirin, atorvastatin, baraclude, fluticasone, furosemide, lisinopril, metoprolol, prednisone, sildenafil, tacrolimus, tiotropium. First Pass PerfusionDuring hyperemia, no perfusion defects were present; however, stress perfusion acquisition was delayed due to IV infiltration and the diagnostic sensitivity is reduced. Viability/ Myocardial ScarThere was late gadolinium enhancement noted at the mid-myocardium at the basal segments (anteroseptum and inferolateral walls). This pattern suggests fibrosis, inflammation, or infiltration, and is not typical of myocardial infarction. The pattern is most consistent with some sort of myocarditis. The rest of the myocardium is viable.Left VentricleThe left ventricle is normal in size with normal systolic function. The overall LV ejection fraction is 64%, the LV end diastolic volume index is 70 ml/m2 (normal range: 74+/-15), the LVEDV is 148 ml (normal range 142+/-34), the LV end systolic volume index is 26 ml/m2 (normal range 25+/-9), the LVESV is 54 ml (normal range 47+/-19), the LV mass index is 52 g/m2, and the LV mass is 110 g. There are no regional wall motion abnormalities present.Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 59%, the RV end diastolic volume index is 72 ml/m2 (normal range 82+/-16), the RVEDV is 152 ml (normal range 142+/-31), the RV end systolic volume index is 29 ml/m2 (normal range 31+/-9), and the RVESV is 62 ml (normal range 54+/-17).Right AtriumThe right atrium is normal in size.Aortic ValveA prosthetic aortic valve was seen at the aortic position. Mitral ValveThe mitral valve opens widely and there is no significant mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is mild 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 pericardial effusion. Significant pericardial fat was noted.Extracardiac FindingsSternal wires were noted. 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. No perfusion defects/ "ischemia" present during hyperemia; however, diagnostic sensitivity reduced due to delayed image acquisition.2. There was late gadolinium enhancement noted at the mid-myocardium at the basal anteroseptum and inferoseptal segments. This pattern suggests fibrosis, inflammation, or infiltration, and is not typical of myocardial infarction. The pattern is most consistent with myocarditis; however, the differential diagnosis includes other things as well3. Normal LV size and systolic function (LVEF 64%).4. Normal RV size and systolic function (RVEF 59%).5. A prosthetic aortic valve was seen at the aortic position.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.