A 57 year old male with history of Mantel Cell Lymphoma treated with autologous stem cell transplant and chest radiation, acute pericarditis, hypertension, diabetes, hyperlipidemia and chronic kidney disease. In 2013 a cardiac CT was performed: non-obstructive 25-50% partially calcified plaque in the Mid LAD with non-obstructive calcified plaques in the first diagonal and right coronary arteries. A recent echocardiography showed stable LVEF of 50% with findings concerning of constriction. The patient was referred to cardiac MRI to rule out ischemia and constriction while he complaints about volume overload without chest pain or shortness of breath.MEDICATIONS: atorvastatin, escitalopram, furosemide, lisinopril, testosterone. First Pass PerfusionDuring hyperemia, no perfusion defects were present. Viability/ Myocardial ScarThere is intermediate signal of late gadolinium enhancement in the mid-myocardium which spares the endocardium at the basal and mid inferior wall. This pattern is atypical for prior myocardial infarction and compatible with a previous myocarditis. The rest of the myocardium is free of late gadolinium enhancement and viable. Left VentricleThe left ventricle is normal in size with low normal systolic function. The overall LV ejection fraction is 52%, the LV end diastolic volume index is 67 ml/m2 (normal range: 74+/-15), the LVEDV is 149 ml (normal range 142+/-34), the LV end systolic volume index is 32 ml/m2 (normal range 25+/-9), the LVESV is 72 ml (normal range 47+/-19), the LV mass index is 46 g/m2, and the LV mass is 101 g. There is a diastolic septal bounce noted. Mild LVH at the basal septum (11mm).Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 51%, the RV end diastolic volume index is 69 ml/m2 (normal range 82+/-16), the RVEDV is 153 ml (normal range 142+/-31), the RV end systolic volume index is 34 ml/m2 (normal range 31+/-9), and the RVESV is 75 ml (normal range 54+/-17).Right AtriumThe right atrium is normal in size.Aortic ValveThe aortic valve opens widely, there is acceleration of flow without obvious stenosis and there is trace aortic regurgitation .Mitral ValveThe mitral valve opens widely and there is mild mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is mild 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 pericardial effusion. There is mild pericardial thickening most pronounced along the basal to mid right ventricular free wall. This portion of the pericardium also demonstrates contrast enhancement consistent with either fibrosis or inflammation. Based on the myocardial tagging images, the pericardium is tethered to the basal to mid lateral wall and also along the apical RV free wall. 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. Mild pericardial thickening associated with gadolinium enhancement, myocardial tethering, and a diastolic septal bounce. These findings are consistent with pericardial constriction; however, the absence of significant IVC, SVC, or atrial dilation, the severity of the constriction may not be very severe. Hemodynamic correlation with echo or catheterization may be helpful to further define the severity of the constriction. 2. There is an small amount of atypical late gadolinium enhancement involving the basal and mid inferior walls. The pattern is not consistent with prior myocardial infarction and supports the diagnosis of prior myocarditis. 3. No evidence of myocardial ischemia. 4. Normal LV size with low normal systolic function (LVEF 52%). 5. Normal RV size and systolic function (RVEF 51%).