83 year old with history of coronary artery disease requiring multiple percutaneous coronary interventions and three vessel coronary artery bypass grafting (LIMA to LAD, SVG to RCA and SVG to OM) and valvular heart disease s/p recent repeat aortic valve replacement and mitral valve repairMEDICATIONS: Amiodarone, aspirin, clopidogrel, triamterene-hydrochlorothiazide First Pass PerfusionDuring hyperemia, extensive perfusion defects involving the entire basal left ventricle, all but the inferolateral wall of the mid left ventricle, and all but the anterior wall of the apical left ventricle. Viability/ Myocardial ScarThere is a small transmural late gadolinium enhancement noted in the mid inferior wall that is consistent with transmural myocardial infarction. This small area (<5% of the myocardium) is unlikely to be viable. The basal septum has a mid-ventricular stripe pattern of late gadolinium enhancement, which is atypical for prior myocardial infarction and suggests the presence of myocardial fibrosis due to a non-ischemic etiology. This segment has an indeterminate probability of viability. The remaining myocardium does not show evidence of myocardial infarction, fibrosis, inflammation, or infiltration and is likely to be viable. Left VentricleThe left ventricle is normal in size and with severely reduced systolic function. The overall LV ejection fraction is 23%, the LV end diastolic volume index is 102 ml/m2 (normal range: 74+/-15), the LVEDV is 205 ml (normal range 142+/-34), the LV end systolic volume index is 78 ml/m2 (normal range 25+/-9), the LVESV is 158 ml (normal range 47+/-19), the LV mass index is 66 g/m2, and the LV mass is 132 g. There is global hypokinesis with additional severe akinesis of the entire inferior wall.. Left AtriumThe left atrium is mildly dilated. Right VentricleThe right ventricle is normal in size with severely reduced systolic function. The overall RV ejection fraction is 28%, the RV end diastolic volume index is 108 ml/m2 (normal range 82+/-16), the RVEDV is 217 ml (normal range 142+/-31), the RV end systolic volume index is 78 ml/m2 (normal range 31+/-9), and the RVESV is 156 ml (normal range 54+/-17).Right AtriumThe right atrium is mildly dilated.Aortic ValveThere is a bioprosthetic aortic valve presentMitral ValveThe mitral valve has posterior leaflet restriction with severe 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.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 FindingsThere are small bilateral pleural effusions. 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 a large burden of ischemia, as described above, in a multivessel coronary distribution. 2. There is a small transmural myocardial infarction in the mid inferior wall. This small area (<5% of the myocardium) is unlikely to be viable. The basal septum has a mid-ventricular stripe pattern of late gadolinium enhancement, which is atypical for prior myocardial infarction and suggests the presence of myocardial fibrosis due to an additional non-ischemic etiology. This segment has an indeterminate probability of viability. The remaining myocardium does not show evidence of myocardial infarction or fibrosis and is likely to be viable. 3. Normal LV size with severely reduced systolic function (LVEF 23%). There is global hypokinesis but the entire inferior wall is clearly worse.4. Normal RV size with severely reduced systolic function (RVEF 28%).5. Mild biatrial dilation.6. Severe mitral regurgitation, likely due to an "ischemic" etiology causing tethering of the posterior leaflet. 7. Small bilateral pleural effusions. 