84 year old man who is s/p mitral valve repair, has chronic atrial fibrillation, history of TIA presents with shortness of breath and newly diagnosed LV dysfunction. He is referred to assess for etiology. First Pass PerfusionDuring hyperemia, no perfusion defects were present; however, a prominent dark rim artifact was noted.Viability/ Myocardial ScarThere was no late gadolinium enhancement noted suggesting that there is no prior myocardial infarction, fibrosis, inflammation, or infiltration. The entire myocardium is viable.Left VentricleThe left ventricle is normal in size with moderately reduced systolic function. The overall LV ejection fraction is 36%, the LV end diastolic volume index is 93 ml/m2 (normal range: 74+/-15), the LVEDV is 190 ml (normal range 142+/-34), the LV end systolic volume index is 59 ml/m2 (normal range 25+/-9), the LVESV is 120 ml (normal range 47+/-19), the LV mass index is 69 g/m2 (normal range 85+/-15), and the LV mass is 140 g (normal range 164+/-36). There is global hypokinesis with regional variation. Abnormal septal motion likely due to known conduction delay and sternotomy. No evidence of myocardial iron overload. Left AtriumThe left atrium is severely dilated. Right VentricleThe right ventricle is normal in size with mildly reduced systolic function. The overall RV ejection fraction is 44%, the RV end diastolic volume index is 84 ml/m2 (normal range 82+/-16), the RVEDV is 171 ml (normal range 142+/-31), the RV end systolic volume index is 47 ml/m2 (normal range 31+/-9), and the RVESV is 96 ml (normal range 54+/-17).Right AtriumThe right atrium is severely dilated.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. A mitral annular ring is noted.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is moderate to severe tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size.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 FindingsAscites with evidence of bowel noted superior to the liver. Hilar and mediastinal lymph nodes are noted. Sternal wires are noted. T2-star relaxation time is reduced in the liver and spleen; however, image quality is degraded by respiratory motion, thus I am not sure if this finding represents iron overload or just artifact. If hepatic or splenic iron overload are a clinical concern, consider dedicated imaging. 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. No perfusion defects/ "ischemia" present during hyperemia; however, the diagnostic sensitivity of vasodilator stress testing in patients with significant LV dysfunction may be reduced. 2. No prior myocardial infarction. The entire myocardium is viable.3. Normal LV size with moderately reduced systolic function (LVEF 36%) without evidence of underlying myocardial fibrosis, inflammation, or infiltration. 4. Normal RV size with mildly reduced systolic function (RVEF 44%).5. Severe biatrial dilation.6. Mitral annuloplasty ring is noted. 7. Moderate to severe tricuspid regurgitation. 8. See extra-cardiac findings. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.