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We describe a case of a 54-year-old male who underwent exercise technetium-99m sestamibi myocardial perfusion imaging prior to his renal transplantation. With exercise, the patient's myocardial perfusion imaging did not show any transient or fixed myocardial perfusion abnormalities due to balanced ischemia. However, wall motion analysis showed a new global left ventricular systolic dysfunction on post-exercise images. Coronary angiography showed severe left main coronary lesion involving ostia of left anterior descending, ramus intermedius and left circumflex coronary arteries with moderate right coronary artery disease. If one had used the perfusion imaging alone in this patient, the severe multivessel disease including left main coronary disease could have been missed. In this article we emphasize the importance of wall motion analysis in patients undergoing myocardial perfusion imaging.