The patient is a 72 year-old man who underwent coronary bypass surgery 6 months ago for a subtotally occluded LAD and other vessel disease. He presented with dizziness and angina after playing paddle-ball. On one occasion he had near syncope and was examined by his daughter-in-law, a nurse, who told him that his blood pressure was only 70mmHg. A stress test done by his cardiologist for angina was positive at a low workload, and the thallium scan showed an anterior wall reperfusable defect. He was referred for diagnostic catheterization and angiography. Blood pressure in the right arm was 170/90, in the left arm 70 by palpation.
The LIMA to the LAD was widely patent as were two saphenous vein grafts. No distal LAD or anastomotic lesions were seen. The pressure in the LIMA was low, however, and on pullback from the L. subclavian to the aorta, a gradient was noted:
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