67 year old man with coronary artery disease s/p 4 vessel CABG and multiple stents. He has recurrence of angina and is referred for location of ischemia.MEDICATIONS: aspirin, clopidogrel, imdur, metoprolol, ramipril, and rosuvastatin First Pass PerfusionDuring hyperemia, there are extensive and severe perfusion defects involving the entire apex, the mid anteroseptal, inferoseptal, and inferior walls, and the entire base except the anterolateral wall.Viability/ Myocardial ScarBased on late gadolinium enhancement imaging, there are 2 distinct myocardial infarctions. The first is a fairly small partially transmural infarction involving the basal inferior and inferoseptal walls. The second is small transmural infarction involving the apical lateral wall. These segments are not likely to be viable; however, the remainder of the myocardium is likely to be viable, including much of the above described ischemic territories and below described wall motion abnormalities. Left VentricleThe left ventricle is normal in size with mildly reduced systolic function. The overall LV ejection fraction is 42%, the LV end diastolic volume index is 102 ml/m2 (normal range: 74+/-15), the LVEDV is 197 ml (normal range 142+/-34), the LV end systolic volume index is 59 ml/m2 (normal range 25+/-9), the LVESV is 113 ml (normal range 47+/-19), the LV mass index is 59 g/m2, and the LV mass is 112 g. There is hypokinesis of th basal to mid inferoseptal, inferior, and inferolateral walls. There is hypokinesis of the mid to apical anterior and anterolateral walls.Left AtriumThe left atrium is normal in sizeRight VentricleThe right ventricle is normal in size and systolic function. The overall RV ejection fraction is 53%, the RV end diastolic volume index is 81 ml/m2 (normal range 82+/-16), the RVEDV is 156 ml (normal range 142+/-31), the RV end systolic volume index is 38 ml/m2 (normal range 31+/-9), and the RVESV is 73 ml (normal range 54+/-17).Right AtriumThe right atrium is normal in sizeAortic 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 mild tricuspid regurgitation.AortaThe aortic root is normal in size. There is a left sided aortic arch with a normal brachiocephalic branching pattern. There is mild to moderate atherosclerosis of the brachiocephalic vessels.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 FindingsSternal wires are 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 extensive ischemia in the usual distribution of the mid LAD and the RCA territories. The ischemic segments are associated with resting wall motion abnormalities and a significant amount of viability.2. There are 2 distinct, small, transmural myocardial infarctions. The first involves the basal inferior and inferoseptal walls. The second involves the apical lateral wall. 3. Normal LV size with mildly reduced systolic function (LVEF 42%) with the above described regional wall motion abnormalities.4. Normal RV size and systolic function (RVEF 53%).