87 year old man with coronary artery disease referred to evaluate for ischemia and viability.MEDICATIONS: aspirin, atorvastatin, lisinopril, metoprolol First Pass PerfusionDuring hyperemia, a perfusion defect of moderate severity was present in the basal inferoseptum, inferior, and inferolateral walls. There is additionally a very mild perfusion defect in the basal anterolateral wall.Viability/ Myocardial ScarThere was no evidence of myocardial infarction; however, there was an atypical mid-wall pattern of late gadolinium enhancement involving the basal inferolateral wall. This pattern is not consistent with myocardial infarction but suggests the presence of underlying myocardial inflammation, fibrosis, or infiltration. The pattern has been described in a variety of disorders ranging from hypertension to old myocarditis. Because there is late gadolinium enhancement in the basal inferolateral wall, it is unclear whether this segment is viable. However, the remainder of the myocardium is free of late gadolinium enhancement and is viable.Left VentricleThe left ventricle is normal in size with moderately reduced systolic function. There is global hypokinesis with regional variation. The overall LV ejection fraction is 36%, the LV end diastolic volume index is 83 ml/m2 (normal range: 74+/-15), the LVEDV is 153 ml (normal range 142+/-34), the LV end systolic volume index is 53 ml/m2 (normal range 25+/-9), the LVESV is 98 ml (normal range 47+/-19), the LV mass index is 60 g/m2, and the LV mass is 110 g. Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size and systolic function. The overall RV ejection fraction is 55%, the RV end diastolic volume index is 71 ml/m2 (normal range 82+/-16), the RVEDV is 131 ml (normal range 142+/-31), the RV end systolic volume index is 32 ml/m2 (normal range 31+/-9), and the RVESV is 58 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 mild 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 mildly dilated.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is a small pericardial effusion.Extracardiac FindingsBilateral small to moderate pleural effusion with neighboring atelectasis is noted (L>R). 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. During hyperemia, a perfusion defect of moderate severity was present in the basal inferoseptum, inferior, and inferolateral walls. There is additionally a very mild perfusion defect in the basal anterolateral wall.2. There was no evidence of myocardial infarction; however, there was an atypical mid-wall pattern of late gadolinium enhancement involving the basal inferolateral wall. This pattern is not consistent with myocardial infarction but suggests the presence of underlying myocardial inflammation, fibrosis, or infiltration. The pattern has been described in a variety of disorders ranging from hypertension to old myocarditis. Because there is late gadolinium enhancement in the basal inferolateral wall, it is unclear whether this particular segment is viable. However, the remainder of the myocardium is free of late gadolinium enhancement and is viable.3. Normal LV size with moderately reduced systolic function (LVEF 36%).4. Normal RV size and systolic function (RVEF 55%).5. Mild dilation of the main pulmonary artery.6. Small pericardial effusion.7. See extra-cardiac findings. 