60 year old man with history of coronary artery disease s/p left main BMS in 2011 and proximal LAD DES in 2015 with left circumflex CTO, referred for cardiac stress MRI to evaluate for inducible ischemia and viability. MEDICATIONS: ASA, Plavix, Lipitor, diltiazem, enalapril. First Pass PerfusionDuring hyperemia, no perfusion defects were present. Viability/ Myocardial ScarThere is a small area of focal late gadolinium enhancement noted in the basal antero-septal wall. It appears intra-myocardial which is an atypical pattern for infarct. This pattern may be due to prior inflammation, infiltration or other non-ischemic fibrotic process. Potentially it may be due to injury in the septal perforator territory. The remainder of the myocardium is viable.Left VentricleThe left ventricle is normal in size with mildly reduced systolic function. There is hypokinesis and associated thinning of the basal to mid anterolateral and infero-lateral walls. Otherwise, there is mild to moderate concentric hypertrophy. The overall LV ejection fraction is 42%, the LV end diastolic volume index is 100 ml/m2 (normal range: 74+/-15), the LVEDV is 181 ml (normal range 142+/-34), the LV end systolic volume index is 59 ml/m2 (normal range 25+/-9), the LVESV is 106 ml (normal range 47+/-19), the LV mass index is 43 g/m2, and the LV mass is 79 g. Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with mildly reduced systolic function. The overall RV ejection fraction is 48%, the RV end diastolic volume index is 73 ml/m2 (normal range 82+/-16), the RVEDV is 133 ml (normal range 142+/-31), the RV end systolic volume index is 33 ml/m2 (normal range 31+/-9), and the RVESV is 69 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 no significant mitral regurgitation.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 bovine arch brachiocephalic branching pattern (innominate artery and left carotid artery sharing a common ostium).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. No perfusion defects/ "ischemia" present during hyperemia; however, there is clearly a resting wall motion abnormality and relative myocardial thinning in the left circumflex territory that does not have any evidence of myocardial infarction. This wall motion abnormality likely represents hibernating myocardium with a high probability of viability despite the absence of demonstratable ischemia on the stress perfusion images (the sensitivity of stress CMR is ~85-90%). 2. There is a small area of late gadolinium enhancement noted in the basal antero-septal wall. It appears intra-myocardial which is an atypical pattern for infarct. This pattern may be due to prior inflammation, infiltration or other non-ischemic fibrotic process. The finding may also represent a myocardial scar in the septal perforator territory.3. Normal LV size and mildly reduced systolic function (LVEF 42%). Aside from the above mentioned region of relative myocardial thinning, there is mild to moderate concentric left ventricular hypertrophy.4. Normal RV size and mildly reduced systolic function (RVEF 48%).I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.