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A 61 year old man presented with a history of chest pain of 13 years’ duration. The frequency and severity of the chest pain had started to increase recently and was associated with shortness of breath at rest. There was no history of hyperlipidaemia and cigarette smoking. The patient was taking aspirin, a diuretic, an angiotensin converting enzyme inhibitor, digitalis, nitrates, and mexiletine. On examination his blood pressure was 130/80 mm Hg and pulse rate 80 beats/min. Auscultation revealed a mild systolic murmur on the apex, with slightly harsh vesicular breathing in the lower zone. A chest x ray showed cardiomegaly, and ECG revealed atrial fibrillation with left ventricular hypertrophy; in the strip trace a few ventricular extrasystoles were seen. Biochemical investigation revealed only hyperlipidaemia with no other pathology. Echocardiography showed that the left ventricular internal diameters were dilated (79 mm/57 mm); ejection fraction was 51%, and a third degree mitral insufficiency was evident. Radionuclide ventriculography was subsequently undertaken which showed significant hypokinesia in the septum and an ejection fraction of 20%.
The patient was admitted and coronary arteriography and ventriculography undertaken. Coronary arteriography showed a normal left anterior descending coronary artery, but in the circumflex (Cx) region neither normal vascular structure nor collateral circulation was evident, suggesting Cx occlusion (below left). Upon selective right coronary arteriography, the Cx artery arose as a terminal extension of the right coronary artery, supplying the Cx region; however, no stenosis was seen (below right). Left ventriculography showed diffuse hypokinesia. The patient was transferred to surgery for mitral valve replacement because of severe left ventricular dysfunction; however, the operation was cancelled and the patient was treated medically.