A 53 year old male with personal history of hypertension, hyperlipidemia, 3 vessels coronary artery bypass graft and mitral valve repair (2012). Recently heart failure symptoms with an echocardiography that showedLVEF of 40%. Referred to stress cardiac MRI for further evaluation. MEDICATIONS: aspirin, atorvastatin, carvedilol, enalapril, hydralazine, isosorbide mononitrate, spironolactone. First Pass PerfusionDuring hyperemia, there is a perfusion defect involving the entire apex apex, all but the mid anterolateral, anterior, anteroseptal, and inferoseptal walls, and the basal inferior and inferolateral walls. Most of these perfusion defects are secondary to the below described transmural myocardial infarctions and not due to ischemia.Viability/ Myocardial ScarThere is are two large transmural myocardial infarctions based on late gadolinium enhancement imaging. The first involves the basal inferior and inferolateral wall. The second involve the mid ventricular anterolateral, anterior, anteroseptal, and inferoseptal walls and the apical anterior, septal, and inferior walls. These segments are not viable. The remainder of the segments are free of myocardial infarction and are likely to be viable.Left VentricleThe left ventricle is severely dilated with moderate-to-severe left ventricular systolic dysfunction. The overall LV ejection fraction is 34%, the LV end diastolic volume index is 114 ml/m2 (normal range: 65+/-11), the LVEDV is 223 ml (normal range 109+/-23), the LV end systolic volume index is 75 ml/m2 (normal range 18+/-5), the LVESV is 146 ml (normal range 31+/-10), the LV mass index is 54 g/m2, and the LV mass is 106 g. Regional wall motion abnormalities corresponding to the above myocardial infarctions are noted.There is no intracavitary thrombus.Left AtriumThe left atrium is normal in size (94ml). Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 55%, the RV end diastolic volume index is 81 ml/m2 (normal range 69+/-14), the RVEDV is 158 ml (normal range 110+/-24), the RV end systolic volume index is 36 ml/m2 (normal range 22+/-8), and the RVESV is 70 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 ValveThere is a mitral valve ring present and there is trace 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. There is a "pseudo-bovine" brachiocephalic branching pattern (normal variant).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 FindingsSternal wires were noted. Small hiatal hernia is noted. 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 are two large transmural myocardial infarctions with only a small amount of residual peri-infarct ischemia involving the apical lateral wall. The segments affected by the myocardial infarctions are not likely to be viable. The remainder of the myocardium is free of myocardial infarction and likely to be viable. 2. Severe LV dilation with moderate to severe systolic dysfunction (LVEF 34%).3. Normal RV size and systolic function (RVEF 55%).4. A mitral valve ring was noted without significant mitral regurgitation.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.