text:  On admission   includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent   white blood cell count 4500   PT and PTT normal . Sodium 140   potassium 4.2   chloride 105   carbon dioxide 30   BUN 24   creatinine 1.0 . HOSPITAL COURSE AND TREATMENT  The patient was admitted to the Cardiac Catheterization Laboratory . There   her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44  17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis   but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition   it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker   she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason   it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20   under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm.   which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase   KS . ACHASTHA N. GRAFT   M.D. TR  hfr DD  08  22  1998 TD  08  27  1998 356 P cc  ACHASTHA NICEMAEN GRAFT   M.D. GITTETUMN DARNNAMAN