This patient with a ventricular septal defect and coarctation of the aorta previously underwent ventricular septal defect surgical patch closure and coarctation repair. Recurrence of the coarctation in a long-segment, however, necessitated placement of an interposition graft (black arrow). Recurrent obstruction is seen at the proximal end of the graft (white arrow). Note pacemaker wires related to post-surgical heart block.