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Coronary milking-like effect caused by systolic expansion of a traumatic focal left ventricular aneurysm

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A 21 year old man was admitted to our centre with multiple fractures of the left femur, ribs, and hip following a car crash. On admission, the ECG showed elevation of the ST segment of 3–4 mm from V2 to V5. An increase in the MB fraction of creatinine kinase was detected. Due to the presence of cardiac tamponade, a pericardiocentesis was performed. Cardiac contusion was diagnosed. Seventy two hours later, the ECG abnormalities had improved and no Q waves were observed.

One week later the ECG showed a 2 mm ST segment depression in leads V4–V6. An echocardiogram revealed a focal left ventricular aneurysm (arrow; LV, left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium.). An angiogram showed normal coronary arteries during the diastole (A) and occlusion of the intermediate artery in systole (B, arrow). This milking-like effect was ascribed to streching or compression of the artery during systolic expansion of the ventricular aneurysm. Since the patient's condition was poor and the cardiac complications did not cause haemodynamic instability, it was decided not perform an aneurysmectomy. It should be noted that the ventricular aneurysm was not irrigated by the narrowed coronary artery, which passed over this area. A bypass venous graft was not indicated since the myocardial damage was secondary to cardiac contusion. To reduce preload and facilitate the myocardial healing and remodelling, an angiotensin converting enzyme inhibitor was given. Acenocumarol was added to the treatment.

Eighteen months later, the ECG was normal and the echocardiogram showed persistence of the aneurysm. A thallium myocardial perfusion study revealed a focal myocardial defect in the anterolateral ventricular segment attributed to the aneurysm. No signs of myocardial ischaemia were detected.