Milking-like effect in the left anterior descending artery secondary to systolic expansion of a post-infarction left ventricular aneurysm

A 68-year-old man with a history of hypertension and smoking presented with prolonged retrosternal chest pain in the previous eight hours. On admission, he was still symptomatic, and an electrocardiography showed Q waves and 3-mm ST segment elevation in leads V2 to V5, I, and aVL. Cardiac catheterization showed an isolated proximal left anterior descending (LAD) coronary artery occlusion (Fig. 1). Percutaneous transluminal coronary angioplasty and stenting with a drug eluting stent (Coracto 3.0×17 mm, DES-CoractoTM) were performed over the residual lesion, with excellent angiography results. The patient was followed up in the cardiac care unit with medical therapy. Serial cardiac enzymes tested positive with a peak level (ultra-sensitive troponin I peak 50000 ng/mL, mass CK-MB peak 300 ng/mL) for myocardial necrosis. Two days later, the patient developed retrosternal angina again. Second cardiac catheterization was performed and showed a sharp milking-like effect, with severe systolic compression in the mid segment of LAD, despite excellent angiographic results (Video 1). A transthoracic echocardiography revealed moderate depression of left ventricular ejection fraction, true left ventricular large anterior wall and apical segments aneurysm, and mild mitral and tricuspid valve insufficiency (Fig. 2). The patient was considered for medical management in the form of necessary medications for acute coronary syndrome in addition to antianginal drugs.