This 70-year-old man with a previous history of CABG developped sudden severe chest pain and called 911. He arrived in the Emergency Department one hour after the onset of his symptoms:

• Sinus rhythm
• ST elevation, consider lateral injury or acute lateral myocardial infarction

The patient was immediately brought to the cardiac catheterization lab, where the circumflex artery and graft to the first obtuse marginal artery (OM1) were occluded. It appeared that the graft to the obtuse marginal branch was the culprit vessel. The lesion was crossed, dilated and grafted. The proximal right coronary artery was completely occluded, and the left anterior descending had 90% proximal stenosis. After dilatation of the OM graft, the patient became symptom-free:

• Sinus rhythm
• Biatrial enlargement
• Lateral infarction

The ST elevation in the lateral leads has improved, in keeping with successful angioplasty of the OM1 graft. It was felt that the 90% stenosis of the LAD could be dilated and stented at a later time if the patient had further angina. The patient remained stable and symptom free until discharge.