PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.

INDICATIONS FOR PROCEDURE: A 59-year-old patient with longstanding
coronary artery disease. He now presents with increasing dyspnea symptoms
which has been angina equivalent in the past. Given this finding along
with the fact that this patient does have profession of a bus driver, we
felt it best to proceed with an invasive risk stratification with at least
an intermediate _____ clinical suspicion for disease progression.

DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was
brought to the cath lab in a fasting condition. He was sterilely prepped
and draped in usual fashion and the right femoral artery entered using a
modified Seldinger technique. A 6-French arterial sheath was easily
established. Following this, left heart catheterization was done with a
6-French JL4 and JR4 catheter being used to perform multiple coronary
angiograms in multiple projections. Afterwards, a 6-French pigtail was
inserted across the aortic valve and into the left ventricle. Hemodynamic
data was gathered. Left ventriculogram was done in the RAO projection.
The catheter was pulled back across the aortic valve, no gradient was
seen. At this point, review of the angiograms finds no obstructive
disease and no significant progression over the prior evaluation.
Therefore, all catheters, wires were removed. The arterial sheath was
removed and hemostasis obtained with manual compression. There were no
immediate complications.

STUDY FINDINGS:
HEMODYNAMICS:
Central aortic pressure was 137/73. Corresponding _____, no gradient
across the aortic valve.

ANGIOGRAPHIC FINDINGS:
Left main: The left main is a moderate size vessel, free of any
significant disease. The LAD has been previously stented in the proximal
and mid vessel. There are some older, Wiktor stents which appear patent.
There is also newer stent which has been placed in the distal portion of the second stent, which remains widely patent with no in-stent restenosis.
The Wiktor stent do not appear to have any high grade in-stent restenosis
either, the more proximal of the two may have some diffuse and perhaps 25
percent narrowing. The more distal LAD is free of any significant
disease.

Left circumflex: The left circumflex is a small system with just mild
irregularities proximally, it gives rise to very tiny obtuse marginal
branch, there is a large ramus intermediate vessel present which is a
bifurcating vessel. This has some diffuse disease at about 25 percent of
the mid portion, but no high-grade lesions are seen. The right coronary
artery is a dominant vessel. It also has a Wiktor stent in the mid
portion, which is widely patent. The ongoing vessel has some mild
plaquing not exceeding 20 percent towards the distal portion, but no high
grade lesions. The posterior descending is a small caliber with long in
length vessel without significant disease. The posterior lateral branch
similarly is long in caliber without significant disease.

Left ventriculogram in the RAO projection demonstrates some mild
hypokinesis to the inferior basal and mid and now toward the inferior
apex. Overall, ejection fraction is estimated to approximately 45-50
percent.

OVERALL IMPRESSION:
1. Nonobstructive coronary artery disease. Previously placed stents
remain widely patent.
2. Mildly reduced left ventricular systolic function, ejection fraction
of approximately 45-50 percent, probably closer to 50 percent.