76 year old man with coronary artery disease s/p TECAB CABG in May 2015. He presents with persistent dyspnea on exertion and referred to evaluate for ischemia and viability.MEDICATIONS: aspirin, clopidogrel, atorvastatin, HCTZ, lisinopril, metoprolol, insulin First Pass PerfusionDuring hyperemia, a large, severe perfusion defect was seen involving the basal and inferolateral and anterolateral walls and also the apical lateral wall. The overall ischemia score is 9 out of 32 and 28% of the ventricle is ischemic.Viability/ Myocardial ScarThe possibility of a small transmural myocardial infarction (i.e. late gadolinium enhancement) involving the basal inferolateral wall can not be excluded. It is unclear if this segment is viable. However, the remainder of the heart is without late gadolinium enhancement and is very likely to be viable. Left VentricleThe left ventricle is normal in size and systolic function. The overall LV ejection fraction is 64%, the LV end diastolic volume index is 48 ml/m2 (normal range: 74+/-15), the LVEDV is 97 ml (normal range 142+/-34), the LV end systolic volume index is 17 ml/m2 (normal range 25+/-9), the LVESV is 35 ml (normal range 47+/-19), the LV mass index is 46 g/m2, and the LV mass is 92 g. There is tardokinesis of the basal inferior wall. Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size and systolic function. The overall RV ejection fraction is 67%, the RV end diastolic volume index is 43 ml/m2 (normal range 82+/-16), the RVEDV is 86 ml (normal range 142+/-31), the RV end systolic volume index is 14 ml/m2 (normal range 31+/-9), and the RVESV is 28 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 no significant 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. Mild atherosclerosis is noted in the descending thoracic aorta.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. There is a large burden of pericardial fat.Extracardiac FindingsThis 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 a large severe perfusion defect during hyperemia, as described above.2. The possibility of a small transmural myocardial infarction (i.e. late gadolinium enhancement) involving the basal inferolateral wall can not be excluded. It is unclear if this segment is viable. However, the remainder of the heart is without late gadolinium enhancement and is very likely to be viable. 3. Normal LV size and systolic function (LVEF 64%). There is tardokinesis of the basal inferior wall.4. Normal RV size and systolic function (RVEF 67%).