54 year old woman with history of premature coronary artery disease with recent NSTEMI and stenting of the circumflex and diagonal branches in July 2016, and diagnosis of right coronary aneurysm. She underwent subsequent nuclear stress demonstrating anterior wall ischemia. She has persistent significant dyspnea with exertion and is referred for vasodilator stress testing as well as coronary imaging.MEDICATIONS: carvedilol, ramipril, atorvastatin, aspirin, nicotine patch First Pass PerfusionDuring hyperemia, no perfusion defects were present. Viability/ Myocardial ScarThere is late gadolinium enhancement in the mid-apical anterior wall of the left ventricle, which involves the endocardium and involves >50% of the myocardial wall. This suggests low probability of viability.Coronary Arteries:The RCA has a normal origin from the right coronary cusp. There is aneurysmal dilation at the mid portion of the vessel which measures 9 x 7mm at its largest diameter. This aneurysmal segment is associated with either a large plaque or thrombus within it. It is surrounded on both the proximal and distal side by a severe stenosis (>70%). Just proximal to the aneurysmal segment, there is an acute marginal take off noted. The left coronary artery is not well seen due to the presence of stent artifacts. Left VentricleThe left ventricle is normal in size with normal systolic function. The overall LV ejection fraction is 63%, the LV end diastolic volume index is 63 ml/m2 (normal range: 65+/-11), the LVEDV is 132 ml (normal range 109+/-23), the LV end systolic volume index is 23 ml/m2 (normal range 18+/-5), the LVESV is 48 ml (normal range 31+/-10), the LV mass index is 37 g/m2, and the LV mass is 78 g. There is mild hypokinesis of the mid anterior wall. Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 58%, the RV end diastolic volume index is 58 ml/m2 (normal range 69+/-14), the RVEDV is 121 ml (normal range 110+/-24), the RV end systolic volume index is 24 ml/m2 (normal range 22+/-8), and the RVESV is 51 ml (normal range 35+/-13). 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 FindingsA gastric band is seen. 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.2. Late gadolinium enhancement in the mid-distal anterior wall which involves the endocardium and >50% of the wall thickness, with associated hypokinesis of these segments. This suggests previous myocardial infarction with low probability of viability. The remainder of the myocardium is free of myocardial infarction and viable.3. Normal LV size and systolic function (LVEF 63%).4. Normal RV size and systolic function (RVEF 58%).5. There is aneurysmal dilation at the mid portion of the RCA which measures 9 x 7mm at its largest diameter. This aneurysmal segment is associated with either a large plaque or thrombus within it. It is surrounded on both the proximal and distal side by a severe stenosis (>70%). Just proximal to the aneurysmal segment, there is an acute marginal take off noted. The left coronary artery is not well seen due to the presence of stent artifacts. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.