PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.surgery, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending