77 year old with history of coronary artery disease who underwent two vessel total endoscopic coronary artery bypass and failed intervention of the right coronary chronic total occlusion presenting for cardiac evaluation. MEDICATIONS: atorvastatin, clopidogrel First Pass PerfusionDuring hyperemia, there is a large burden of ischemia. There is a transmural perfusion defect involving the basal infero-septum, inferior, and inferolateral walls. There is a non-transmural perfusion defect involving the basal anteroseptum, anterior, and anterolateral walls. At the mid ventricular level, there is a non-transmural perfusion defect involving the inferoseptal and inferior walls. At the apical level, there is a mild circumferential perfusion defect. Viability/ Myocardial ScarThere is a small transmural myocardial infarction limited to the basal inferior wall. This segment is unlikely to be viable; however, the remainder of the myocardium is viable. Left VentricleThe left ventricle is normal in size and systolic function. The overall LV ejection fraction is 63 %, the LV end diastolic volume index is 61 ml/m2 (normal range: 74+/-15), the LVEDV is 115 ml (normal range 142+/-34), the LV end systolic volume index is 23 ml/m2 (normal range 25+/-9), the LVESV is 43 ml (normal range 47+/-19), the LV mass index is 47 g/m2, and the LV mass is 88 g. There is mild hypokinesis of the basal inferior wall. 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 63%, the RV end diastolic volume index is 63 ml/m2 (normal range 82+/-16), the RVEDV is 117 ml (normal range 142+/-31), the RV end systolic volume index is 23 ml/m2 (normal range 31+/-9), and the RVESV is 44 ml (normal range 54+/-17).Right AtriumThe right atrium is mildly enlarged.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is mild to moderate mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is trace 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. There is atherosclerosis seen in the descending thoracic aorta. 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 large burden of ischemia in a multivessel coronary distribution.2. The most severe defect is in the usual territory of the right coronary. Although a small portion of this territory has a transmural myocardial infarction which is not viable, most of the RCA territory is free of myocardial infarction and highly likely to be viable. 3. There is also mild ischemia in the other coronary artery territories. There is no myocardial infarction in these areas and they are highly likely to be viable. 4. Normal LV size and systolic function (LVEF 63%).5. Normal RV size and systolic function (RVEF 63%).6. Mild to moderate mitral regurgitation. 