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Relevant clinical history and physical exam
A 65 year-old male patient visited the outpatient clinic due to exertional chest pain for 3 months. The patient underwent PCI to proximal LAD 2 years ago. He did not have hypertension or diabetes. Physical examination was unremarkable.
Relevant test results prior to catheterization
Twelve-lead electrocardiogram and echocardiography was normal. Myocardial perfusion SPECT showed a reversible perfusion decrease in anterior wall with a total perfusion defect of 13%.
Relevant catheterization findings
A previous stent in LAD was patent and the other vessels had no significant stenosis. In order to exclude the possibility of reverse mismatch, fractional flow reserve (FFR) measured. Resting Pd/Pa was 0.95 and FFR during induced hyperemia was 0.86.
This case shows a mismatch between angiogram and non-invasive functional test. Also, there was a mismatch between the size and territory of a diagonal branch. Confirmation of clinical relevance of a diagonal branch can be examined during PCI. Diagonal branch lesions are different in anatomical, physiologic findings and prognosis from lesions in LAD. Treatment strategies for diagonal branch should be established.