A 78 year old male with mitral valve posterior leaflet flail and severe regurgitation, diabetes mellitus, hypertension, coronary artery disease, s/p CABG (1994), mesothelioma s/p thoracotomy (1992), and metastatic neuroendocrine carcinoma. Now admitted to neurology because of bilateral leg weakness, CT showed large mass in liver, portocaval and retroperitoneal lymphadenopathy, PET showed increased uptake in liver, lymph nodes and at the right side of the heart. Echocardiography showed severe mitral regurgitation, no pericardial effusion and no mass. Referred to cardiac MRI for further evaluation. Left VentricleThe left ventricle is mildly dilated with mildly reduced systolic function. The overall LV ejection fraction is 48%, the LV end diastolic volume index is 110 ml/m2 (normal range: 74+/-15), the LVEDV is 202 ml (normal range 142+/-34), the LV end systolic volume index is 57 ml/m2 (normal range 25+/-9), the LVESV is 105 ml (normal range 47+/-19), the LV mass index is 54 g/m2 (normal range 85+/-15), and the LV mass is 99 g (normal range 164+/-36). There is akinesis of the anterior wall and hypokinesis of the antero-lateral wall at the mid-to-apical segments. There is transmural late gadolinium enhancement in the pattern of a prior myocardial infarction located from the mid to apical anterior wall. Left AtriumThe left atrium is mildly dilated. Right VentricleThe right ventricle is normal in size with mildly reduced systolic function. The overall RV ejection fraction is 45%, the RV end diastolic volume index is 80 ml/m2 (normal range 82+/-16), the RVEDV is 147 ml (normal range 142+/-31), the RV end systolic volume index is 44 ml/m2 (normal range 31+/-9), and the RVESV is 81 ml (normal range 54+/-17).Right AtriumThe right atrium is normal in size.MassThere is an irregular shaped mass at the RA and IVC junction, sized 18 X 16 mm, characterized to be heterogeneous but low signal on T1 weighted images, heterogeneous but high signal on T2-weighted images, the mass contrast enhances heterogeneously in a delayed manner. It does not appear to invade into the adjacent right atrium or IVC. The mass is concerning for malignancy.Aortic ValveThe aortic valve is trileaflet and has significant aortic valve stenosis and mild aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is severe eccentric mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is mild pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is mild tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size. Mild protruding atheroma in the descending thoracic aorta. Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is moderately dilated.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is a trivial pericardial effusion without obvious pericardial thickening.Extracardiac FindingsLarge right and small left pleural effusion. The right pleural effusion has a heterogeneous signal suggesting it may be non-transudative. Sternal 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. There is an irregular shaped mass at the RA and IVC junction, sized 18 X 16 mm, characterized to be heterogeneous but low signal on T1 weighted images, heterogeneous but high signal on T2-weighted images, the mass contrast enhances heterogeneously in a delayed manner. It does not appear to invade into the adjacent right atrium or IVC. The mass is concerning for malignancy.2. Mild LV dilation with mildly reduced systolic function (LVEF 48%) with evidence of an apical aneurysm.3. There is a transmural myocardial infarction involving the mid to apical anterior wall. 4. Normal RV size with mildly reduced systolic function (RVEF 45%). 5. Severe mitral regurgitation with an anteriorly directed eccentric jet. 6. At least moderate aortic valve stenosis with mild aortic regurgitation, correlation with echocardiography suggested to quantify severity. 7. See extra-cardiac findings. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.