65 year old man with prior myocardial infarction referred to evaluate for ischemia and viability.MEDICATIONS: simvastatin, atenolol, aspirin, enalapril, omega 3 supplements. First Pass PerfusionDuring hyperemia, perfusion defects corresponding to the below described transmural myocardial infarctions were noted in the basal anterior and anteroseptal walls, mid anterior and anteroseptal walls, and the apical inferior, anterior, and septal walls (i.e LAD territory). Additionally, perfusion defects independent of scar representing mild residual ischemia were seen in the mid anterolateral walls and the apical lateral wall (i.e. LCx territory). Viability/ Myocardial ScarThere is a large transmural myocardial infarction (i.e. late gadolinium enhancement) with associated fatty replacement involving the basal anterior and anteroseptal walls, the mid anterior and anteroseptal walls, and the apical anterior, septal, and inferior walls). These segments (LAD territory) are unlikely to be viable. The remainder of the myocardium (i.e. LCx and RCA territory) is free of myocardial infarction and is likely to be viable. Left VentricleThe left ventricle is normal in size with normal systolic function with regional wall motion abnormalities as described below. The overall LV ejection fraction is 64%, the LV end diastolic volume index is 77 ml/m2 (normal range: 74+/-15), the LVEDV is 151 ml (normal range 142+/-34), the LV end systolic volume index is 28 ml/m2 (normal range 25+/-9), the LVESV is 55 ml (normal range 47+/-19), the LV mass index is 57 g/m2, and the LV mass is 110 g. There is hypokinesis of the entire anterior wall and the anteroseptal wall. There is also hypokinesis of the apical inferior wall.Left AtriumThe left atrium is mildly dilated. Right VentricleThe right ventricle is normal in size and systolic function. The overall RV ejection fraction is 76%, the RV end diastolic volume index is 74 ml/m2 (normal range 82+/-16), the RVEDV is 143 ml (normal range 142+/-31), the RV end systolic volume index is 18 ml/m2 (normal range 31+/-9), and the RVESV is 34 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 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. There is a transmural infarction involving much of the LAD territory and it is unlikely to be viable.2. There is mild ischemia in the LCx territory and is likely to be viable.3. Normal LV size and systolic function (LVEF 64%). There is hypokinesis of the the entire anterior and anteroseptal walls and the apical inferior wall.4. Normal RV size and systolic function (RVEF 76%).5. Mild dilation of the left atrium.