Investigations: 
Transthoracic echocardiography (TTE) was significant for severe bioprosthetic aortic valve stenosis with moderate to severe paravalvular regurgitation (peak velocity 3.7 m/s, DVI 0.24, acceleration time > 100ms with mean gradient 35mmHg) (Figure A) . Left ventricular ejection fraction was 46%. Additionally, pulmonic valve stenosis was identified with peak/mean gradient of 66/41 mm Hg and max velocity 4.0 m/s. Angiography demonstrated occluded LIMA to LAD graft with the native LAD supplied by the native left main, and total occlusion of the native LCX with patent SVG to the LCx.  A right heart catheterization (RHC) was remarkable for severely elevated right ventricular systolic pressure of 102 mm Hg (Figure B).Pulmonary artery pressure (PAP) was 32/15 mm Hg with mean PAP of 22 mm Hg.