69 year old man with history of anterior wall MI with chronic LAD occlusion, LV thrombus and LV dysfunction with worsening angina; referred for cardiac MRI to evaluate ischemic and scar burden.MEDICATIONS: aspirin, atorvastatin, lopressor, warfarin, lisinopril First Pass PerfusionDuring hyperemia, extensive amount of the myocardium had evidence of a perfusion defect. The mid ventricle and apex had a perfusion defect, as did the basal anterior and anteroseptal walls. Viability/ Myocardial ScarThere is a very large, nearly transmural infarction involving the basal anterior and anteroseptal walls remainder of the myocardium is viable. Left VentricleThe left ventricle is moderate to severely dilated with moderately reduced systolic dysfunction. The overall LV ejection fraction is 36%, the LV end diastolic volume index is 134 ml/m2 (normal range: 74+/-15), the LVEDV is 292 ml (normal range 142+/-34), the LV end systolic volume index is 86 ml/m2 (normal range 25+/-9), the LVESV is 187 ml (normal range 47+/-19), the LV mass index is 57 g/m2 (normal range 85+/-15), and the LV mass is 125 g (normal range 164+/-36). There is thinning of the entirely of the apical segments with associated aneurysmal formation. There is laminated thrombus within the aneurysm. There is additionally mild hypokinesis of the basal inferolateral wall. Left AtriumThe left atrium is severely dilated. Right VentricleThe right ventricle is normal in size with hyperdynamic systolic function. The overall RV ejection fraction is 63%, the RV end diastolic volume index is 81 ml/m2 (normal range 82+/-16), the RVEDV is 176 ml (normal range 142+/-31), the RV end systolic volume index is 30 ml/m2 (normal range 31+/-9), and the RVESV is 66 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 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 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. A large burden of the myocardium has evidence of perfusion defects during hyperemia, which corresponds to multi-vessel coronary artery diease. The perfusion defect in the LAD territory is associated with a large myocardial infarction which involves 40-50% of the wall thickness. This territory has a low to intermediate probability of viability. The RCA and LCx territories also have evidence of perfusion defect/ "ischemia"; however, these territories have no associated myocardial infarction and are highly likely to be viable. 2. The left ventricle is moderate to severely dilated with moderately reduced systolic dysfunction (EF 36%). There is a large apical aneurysm with evidence of a laminated thrombus. 3. The right ventricle is normal in size with hyperdynamic systolic function (EF 63%).I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.