A 54 year old male with a clinical picture of myocarditis 1 month ago with normal coronary arteries in the catheterization, severe left ventricular dysfunction was shown in the echocardiography. Now referred to cardiac MRI for further evaluation. Left VentricleThe left ventricle is severely dilated with severe systolic dysfunction. The overall LV ejection fraction is 18%, the LV end diastolic volume index is 168 ml/m2 (normal range: 74+/-15), the LVEDV is 326 ml (normal range 142+/-34), the LV end systolic volume index is 137 ml/m2 (normal range 25+/-9), the LVESV is 266 ml (normal range 47+/-19), the LV mass index is 75 g/m2 (normal range 85+/-15), and the LV mass is 145 g (normal range 164+/-36). There is global hypokinesis with regional variation. There is late gadolinium enhancement: atypical mid-myocardial pattern in the mid septum, transmural pattern at the apex in the lateral and inferior segments. This finding suggest the presence of fibrosis, inflammation, or infiltration. Although, the apical abnormality could represent a prior myocardial infarction, given the fact that there is another associated region of LGE which is not of myocardial infarction pattern, the most likely etiology is that both regions of LGE are secondary to the same phenomenon and consistent with the diagnosis of myocarditis. There is minimal residual increased myocardial T2-signal suggesting that the myocarditis is no longer in the acute phase and not very actively inflamed. A mural thrombus at the apex was noted (6X11mm).Left AtriumThe left atrium is moderately dilated. Right VentricleThe right ventricle is normal in size with moderately reduced systolic function. The overall RV ejection fraction is 36%, the RV end diastolic volume index is 111 ml/m2 (normal range 82+/-16), the RVEDV is 216 ml (normal range 142+/-31), the RV end systolic volume index is 71 ml/m2 (normal range 31+/-9), and the RVESV is 138 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 to moderate 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.AortaThere is a left sided aortic arch. There is anomalous origin of the right subclavian artery, which originates just distal to the left subclavian artery and travels posterior to the esophagus as it courses to the right arm. The aortic root is normal in size.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 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. The left ventricle is severely dilated with severe systolic dysfunction, the LVEF is 18%. There is global hypokinesis with regional variation.2. There are 2 distinct patches of late gadolinium enhancement. The first involves the mid septum and is in a non-coronary pattern. The segment is associated with small areas of mildly increased T2-signal suggesting it most likely represents sub-acute myocarditis. The second region involves the apical inferior and apical lateral walls. It is transmural in pattern. Although the finding usually suggests prior myocardial infarction, in the setting of his other non-MI pattern LGE, it probably is also due to myocarditis. This region does not have increased T2-signal and is not likely to have residual inflammation. 3. A mural thrombus is noted in the LV apex.4. The left atrium is moderately dilated. 5. The right ventricle is normal in size with moderately reduced systolic function, the RVEF is 36%. 6. There is mild to moderate mitral regurgitation. 7. There is mild tricuspid regurgitation.8. Anomalous origin of the right subclavian artery (Lusoria anomaly).After reviewing study with his clinic physician's team, patient was asked to report to ER to consider initiation of anticoagulation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.