77 year old woman with ischemic cardiomyopathy. She is referred to evaluated for ischemia and viability.MEDICATIONS: ASA, clopidogrel, enalapril, furosemide, metoprolol, atorvastatin. First Pass PerfusionDuring hyperemia, two perfusion defects were noted: One in the basal anterolateral wall and another involving much of the inferoseptum and inferior walls. Viability/ Myocardial ScarThere was late gadolinium enhancement involving the basal and mid anterolateral and inferolateral walls. The pattern was consistent with a large sub-endocardial myocardial infarction. These segments have an intermediate probability of viability. The remainder of the myocardium is free of myocardial infarction and is likely to be viable. Left VentricleThe left ventricle is severely dilated with severely reduced systolic function. The overall LV ejection fraction is 29%, the LV end diastolic volume index is 158 ml/m2 (normal range: 65+/-11), the LVEDV is 273 ml (normal range 109+/-23), the LV end systolic volume index is 113 ml/m2 (normal range 18+/-5), the LVESV is 195 ml (normal range 31+/-10). There is global hypokinesis with regional variation.Left AtriumThe left atrium is severely dilated. Right VentricleThe right ventricle is moderately dilated with moderately reduced systolic function. Right AtriumThe right atrium is mild to moderately dilated. Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is moderate mitral regurgitation with bileaflet tethering.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 mildly dilated.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium. PericardiumThere is no obvious pericardial disease.Extracardiac FindingsA nodule is noted (1.3x1.4cm) in the posterior aspect of the right lung apex. A smaller nodule is also noted in the left upper lung. These nodules were not present on a CT scan from 2007; however, a previously noted lipoma in the right upper lung is noted once again today. 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. Two perfusion defects are noted during hyperemia. The smaller one involves the basal anterolateral wall, and a larger one involves most of the inferoseptal and inferior walls. The diagnostic sensitivity of vasodilator stress testing in individuals with severe LV dysfunction may be limited.2. A large non-transmural myocardial infarction is noted in the basal and mid anterolateral and inferolateral walls. These segments have an intermediate probability of viability. The remainder of the myocardium is free of myocardial infarction and is likely to be viable.3. Severe LV dilation with severely reduced systolic function (LVEF 29%).4. Moderate RV dilation with moderately reduced systolic function.5. Moderate mitral regurgitation. 6. Severe left atrial dilation.7. Mild dilation of the main pulmonary artery.8. Lung findings as described above. Consider dedicated chest CT imaging if clinically indicated.These findings were conveyed to Dr. Polonsky.