EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.surgery, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft