38 year old male with history of anti-phospholipid antibody syndrome, CKD s/p kidney transplant, CAD s/p DES x3 in 11/2014 now with recurrent angina who presents for stress CMR to evaluate for ischemia.MEDICATIONS: asa 81mg, plavis 75mg, lipitor 80mg, coreg 25mg bid, benazepril 20mg daily, imdur 60mg daily, amlodipine 10mg daily First Pass PerfusionDuring hyperemia, there are two perfusion defects noted. The first is a mild subendocardial perfusion defect involving the basal to mid inferior wall. The second is a moderate subendocardial perfusion defect involving the mid to apical anterior wall. Viability/ Myocardial ScarThere is a small, focal transmural infarct in the mid anterior wall. The amount of ischemia in the anterior wall is out of proportion to the amount of infarct; there is concern for peri-infarct ischemia in the LAD territory.There is also a small non-transmural infarct in the basal to mid inferior wall that is viable. This area of infarct coincides with the inferior perfusion defect described above. The remainder of the myocardium is viable.Left VentricleThe left ventricle is moderately enlarged with normal systolic function. The overall LV ejection fraction is 55%, the LV end diastolic volume index is 126 ml/m2 (normal range: 74+/-15), the LVEDV is 282 ml (normal range 142+/-34), the LV end systolic volume index is 57 ml/m2 (normal range 25+/-9), the LVESV is 128 ml (normal range 47+/-19), the LV mass index is 88 g/m2, and the LV mass is 198 g. There are no regional wall motion abnormalities present. There is mild hypokinesis seen in the basal to mid inferior wall and in the mid anterior wall.There is no LV thrombus. Left AtriumThe left atrium is moderately dilated. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 60%, the RV end diastolic volume index is 112 ml/m2 (normal range 82+/-16), the RVEDV is 250 ml (normal range 142+/-31), the RV end systolic volume index is 45 ml/m2 (normal range 31+/-9), and the RVESV is 101 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. The right subclavian artery arises aberrantly from the proximal descending aorta with a retroesophageal course. 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 a trace pericardial effusion.Extracardiac FindingsThere are small bilateral pleural effusions and bilateral renal atrophy with cysts.
1. There are two perfusion defects/ "ischemia" as described above in the LAD and RCA territory. The inferior perfusion defect is in the area of a subendocardial basal to mid non-transmural inferior infarct. This area is viable. There is a very small, focal mid transmural anterior infarct with peri-infarct ischemia noted in the mid to apical anterior wall. There is mild hypokinesis noted in the both territories. The remainder of the myocardium is viable.2. Moderately dilated LV size with normal systolic function (LVEF 55%)3. Normal RV size and systolic function (RVEF 60%).4. In comparison to the study performed 8/27/2014, there is now ischemia in the LAD territory. There is now a non-transmural infarct in the area of inferior ischemia noted on the last exam.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.