63 year old male with a history of coronary artery disease, hypertension, hyperlipidemia, diabetes. Patient is s/p myocardial infarction in 7/2016 s/p PCI to LAD, s/p PCI to left circumflex in 8/2016, chronic total occlusion of RCA. Left VentricleThe left ventricle is moderately dilated and severely reduced systolic function. The overall LV ejection fraction is 25%, the LV end diastolic volume index is 131 ml/m2 (normal range: 74+/-15), the LVEDV is 274 ml (normal range 142+/-34), the LV end systolic volume index is 98 ml/m2 (normal range 25+/-9), the LVESV is 206 ml (normal range 47+/-19), the LV mass index is 51 g/m2 (normal range 85+/-15), and the LV mass is 107 g (normal range 164+/-36). There is global hypokinesis with akinesis of the mid anteroseptum and the apical anterior and septal walls. There is a transmural myocardial infarction involving the mid anteroseptum and apical anterior and septal walls. These segments are not likely to be viable. There is another small focal basal anterior myocardial infarction which is transmural and not likely to be viable. There is also third region of late gadolinium enhancement which involves the epicardium of the basal 2cm of the inferior and inferolateral walls. The pattern of late gadolinium enhancement is not consistent with prior myocardial infarction and suggests the presence of an underlying fibrosing, infiltrative, or inflammatory process. There are large territories of myocardium which are free of myocardial infarction and likely to be viable (Most of RCA and LCX territory and most of the proximal and LAD territory). The native myocardial T1 relaxation times are mild to moderately increased (1100-1200msec suggesting diffuse myocardial fibrosis). There is no evidence of myocardial iron overload. No LV thrombus noted. Left AtriumThe left atrium is severely dilated. 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 64 ml/m2 (normal range 82+/-16), the RVEDV is 134 ml (normal range 142+/-31), the RV end systolic volume index is 29 ml/m2 (normal range 31+/-9), and the RVESV is 61 ml (normal range 54+/-17).Right AtriumThe right atrium is normal sized.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 no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size.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 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. The left ventricle is moderately dilated with severely reduced systolic function (LVEF 25%). The LV dysfunction is likely due to a dual pathology (ischemic and non-ischemic). There is a small transmural myocardial infarction in the basal anterior wall and a second larger transmural myocardial infarction involving the distal LAD territory. These territories are not likely to be viable. The remainder of the myocardium (most of RCA and LCx and some of proximal and mid LAD territory) is free of myocardial infarction and likely to be viable. There is also epicardial late gadolinium enhancement involving the basal 2cm of the inferior and inferolateral walls. This pattern is not consistent with prior myocardial infarction and suggests the presence of underlying myocardial fibrosis, inflammation, or infiltration. 2. The right ventricle is normal in size and systolic function (RVEF 55%). 3. There is mild to moderate mitral regurgitation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.