68 year old man with ischemic cardiomyopathy, history of CABG, atrial fibrillation who now has lymphoma and is referred for evaluation of ischemia and viability prior to chemotherapy.MEDICATIONS: carvedilol, lisinopril, pradaxa. First Pass PerfusionDuring hyperemia, two large distinct perfusion defects were noted. The first involves the basal to mid inferoseptum and the basal inferior and inferolateral walls. The second involves the mid anteroseptum and all the apical segments.Viability/ Myocardial ScarThere was a transmural myocardial infarction involving the entire LV apex and mid inferoseptal and inferior walls, which corresponds to the second perfusion defect described above. These segments are not likely to be viable. The remainder of the myocardium is free of myocardial infarction and is likely to be viable. Left VentricleThe left ventricle is moderately dilated with moderately reduced systolic function. There is hypokinesis of the basal to mid inferior and inferoseptal walls. There is akinesis of all the apical segments. The overall LV ejection fraction is 32%, the LV end diastolic volume index is 125 ml/m2 (normal range: 74+/-15), the LVEDV is 274 ml (normal range 142+/-34), the LV end systolic volume index is 85 ml/m2 (normal range 25+/-9), the LVESV is 186 ml (normal range 47+/-19), the LV mass index is 81 g/m2, and the LV mass is 177 g. No evidence of LV thrombus.Left AtriumThe left atrium is moderately dilated. Right VentricleThe right ventricle is normal in size and systolic function. The overall RV ejection fraction is 50%, the RV end diastolic volume index is 94 ml/m2 (normal range 82+/-16), the RVEDV is 207 ml (normal range 142+/-31), the RV end systolic volume index is 48 ml/m2 (normal range 31+/-9), and the RVESV is 104 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 mild mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is mild to moderate 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. Clips for 2 saphenous vein grafts are noted in the ascending aorta. Clips for a left internal mammary artery graft are also noted. Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is mildly dilated.Venous AnatomyThe SVC is normal in size and drains normally into the right atrium. The IVC is dilated suggesting increased right atrial pressure.PericardiumThere is no obvious pericardial disease.Extracardiac FindingsSternal wires are noted. A large burden of mediastinal and axillary lymph nodes noted. Large right pleural effusion. Trace left pleural effusion. 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 akinesis of the distal LAD territory which has a transmural myocardial infarction and is unlikely to be viable.2. There is large amount of ischemia in the usual territory of the right coronary artery. This territory is associated with hypokinesis and is highly likely to be viable. 3. The remainder of the myocardium is viable and without significant ischemia. 4. Moderate LV dilation with moderately reduced systolic function (LVEF 32%) without evidence of LV thrombus.5. Normal RV size and systolic function (RVEF 50%).6. Moderate left atrial dilation.7. Mild dilation of the main pulmonary artery.8. Extra-cardiac findings as described above. 