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• W2007760761 abstract "Pulsus alternans is usually a systolic phenomenon. We present a case of a patient with severe heart failure, and systolic and diastolic pulsus alternans. This case may help clarify the mechanism of pulsus alternans. Pulsus alternans is usually a systolic phenomenon. We present a case of a patient with severe heart failure, and systolic and diastolic pulsus alternans. This case may help clarify the mechanism of pulsus alternans. Case ReportA 27-year-old woman presented to the hospital with several weeks of increasing dyspnea on exertion, decreased effort tolerance, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema after an acute viral illness 1 month earlier. Physical examination was remarkable for a regular heart rate of 120/min, a systolic blood pressure that alternated between 90 and 100 mm Hg, elevated jugular venous pressure, an S3 gallop, and rales over both lungs.Echocardiography demonstrated a severely dilated and hypokinetic left ventricle (LV), an ejection fraction of 20%, and mild mitral regurgitation (MR). Continuous wave Doppler tracings showed beat-to-beat variation in transaortic flow velocity, with the peak velocity alternating between 0.8 and 0.4 m/s (Figure 1). The transmitral flow velocity demonstrated beat-to-beat variation as well, with a peak velocity alternating between 1.2 and 0.8 m/s (Figure 2). Alternating dP/dt on the MR tracing was also noted, with higher dP/dt in the beat following the higher early diastolic mitral inflow (E) velocity, and lower dP/dt following the beats with lower E (Figure 2). Pulsed tissue Doppler at the mitral annulus demonstrated alternating systolic and diastolic tissue velocities. Peak systolic velocity alternated between 3 and 2 cm/min. The peak early diastolic velocity alternated between 8 and 6 cm/s (Figure 3).Figure 2Continuous wave Doppler of transmitral flow velocity. Marked beat-to-beat alternation in diastolic mitral inflow pattern is noted. Despite being in sinus rhythm, E and A wave of mitral inflow velocity are fused because of patient’s significant tachycardia. Peak velocity alternates between 1.2 and 0.8 m/s. This represents diastolic alternans possibly resulting in alternating loading conditions. Also noted, alternating dP/dt on mitral regurgitation (MR) tracing, with higher dP/dt in beat following the higher E velocity, and lower dP/dt following the beats with lower E.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Pulsed wave tissue Doppler at lateral mitral annulus. Significant beat-to-beat variation in both systolic and diastolic tissue velocities is noted. Peak systolic velocity alternates between 3 and 2 cm/min. Peak early diastolic velocity alternates between 8 and 6 cm/s.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The patient was treated with intravenous diuretics and responded well. Angiotensin-converting enzyme inhibitor, a beta-blocker, and spironolactone were started. Echocardiography was repeated a few days after her admission and showed no change in ejection fraction or MR. However, there was no further clinical or echocardiographic evidence of pulsus alternans (systolic or diastolic).DiscussionPulsus alternans refers to alternating force of a palpable arterial pulse as a result of alternating LV stroke volumes (at constant R-R intervals), giving rise to beat-to-beat variability in systolic blood pressure. It is a known clinical sign of LV systolic dysfunction and is a marker of poor prognosis. Although it was described many years ago, the exact mechanism remains incompletely understood.1Edwards P. Cohen G.I. Both diastolic and systolic function alternate in pulsus alternans: a case report and review.J Am Soc Echocardiogr. 2003; 16: 695-697Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The proposed mechanisms have been of two major categories: contractile and hemodynamic.The contractile mechanism refers to alternating force of LV contraction. The role of calcium has been addressed with a possible role for alteration in the levels of intracellular calcium or the size of the calcium current.2McGaughey M.D. Maughan W.L. Sunagawa K. Sagawa K. Alternating contractility in pulsus alternans studied in the isolated canine heart.Circulation. 1985; 71: 357-362Crossref PubMed Scopus (51) Google ScholarThe hemodyanmic theory assumed beat-to-beat changes in preload conditions, resulting in beat-to-beat changes in systolic function, based on the Frank-Starling mechanism. More forceful beats result from increased preload, causing more complete emptying of the LV, such that the following beat starts with a smaller preload, thus, reducing the contractility. This was not accepted as the sole mechanism of pulsus alternans, as up until today variations in mitral inflow could not be demonstrated.3Lab M.J. Lee J.A. Changes in intracellular calcium during mechanical alternans in isolated ferret ventricular muscle.Circ Res. 1990; 66: 585-595Crossref PubMed Scopus (120) Google ScholarCostello et al4Costello D.L. Gaasch W.H. Criscitiello M.G. Echocardiographic examination in left ventricular alternans.Chest. 1979; 75: 72-75Crossref PubMed Scopus (6) Google Scholar described M-mode echocardiographic evaluation of pulsus alternans in a patient with cardiomyopathy after an acute viral illness. They were able to demonstrate LV systolic alternans, associated with early diastolic alternans of the mitral valvular motion, and alternating intensity of S3 gallop.Our case may help shed light on this problem. We demonstrated concomitant systolic and diastolic pulsus alternans, which disappeared as the patient’s hemodynamic status improved. We also demonstrated alternating tissue velocities (both in systole and diastole), further emphasizing the alternating myocardial mechanics in both phases of the cardiac cycle. Finally, we were able to demonstrate alternations in the LV contractility measured by the dP/dt (as calculated from the MR jet) with faster dP/dt in the beats with higher mitral inflow velocity, and lower dP/dt in the beats with lower mitral inflow velocity. This supports the theory of alternating loading conditions as a possible part of the mechanism of systolic pulsus alternans. Case ReportA 27-year-old woman presented to the hospital with several weeks of increasing dyspnea on exertion, decreased effort tolerance, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema after an acute viral illness 1 month earlier. Physical examination was remarkable for a regular heart rate of 120/min, a systolic blood pressure that alternated between 90 and 100 mm Hg, elevated jugular venous pressure, an S3 gallop, and rales over both lungs.Echocardiography demonstrated a severely dilated and hypokinetic left ventricle (LV), an ejection fraction of 20%, and mild mitral regurgitation (MR). Continuous wave Doppler tracings showed beat-to-beat variation in transaortic flow velocity, with the peak velocity alternating between 0.8 and 0.4 m/s (Figure 1). The transmitral flow velocity demonstrated beat-to-beat variation as well, with a peak velocity alternating between 1.2 and 0.8 m/s (Figure 2). Alternating dP/dt on the MR tracing was also noted, with higher dP/dt in the beat following the higher early diastolic mitral inflow (E) velocity, and lower dP/dt following the beats with lower E (Figure 2). Pulsed tissue Doppler at the mitral annulus demonstrated alternating systolic and diastolic tissue velocities. Peak systolic velocity alternated between 3 and 2 cm/min. The peak early diastolic velocity alternated between 8 and 6 cm/s (Figure 3).Figure 3Pulsed wave tissue Doppler at lateral mitral annulus. Significant beat-to-beat variation in both systolic and diastolic tissue velocities is noted. Peak systolic velocity alternates between 3 and 2 cm/min. Peak early diastolic velocity alternates between 8 and 6 cm/s.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The patient was treated with intravenous diuretics and responded well. Angiotensin-converting enzyme inhibitor, a beta-blocker, and spironolactone were started. Echocardiography was repeated a few days after her admission and showed no change in ejection fraction or MR. However, there was no further clinical or echocardiographic evidence of pulsus alternans (systolic or diastolic). A 27-year-old woman presented to the hospital with several weeks of increasing dyspnea on exertion, decreased effort tolerance, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema after an acute viral illness 1 month earlier. Physical examination was remarkable for a regular heart rate of 120/min, a systolic blood pressure that alternated between 90 and 100 mm Hg, elevated jugular venous pressure, an S3 gallop, and rales over both lungs. Echocardiography demonstrated a severely dilated and hypokinetic left ventricle (LV), an ejection fraction of 20%, and mild mitral regurgitation (MR). Continuous wave Doppler tracings showed beat-to-beat variation in transaortic flow velocity, with the peak velocity alternating between 0.8 and 0.4 m/s (Figure 1). The transmitral flow velocity demonstrated beat-to-beat variation as well, with a peak velocity alternating between 1.2 and 0.8 m/s (Figure 2). Alternating dP/dt on the MR tracing was also noted, with higher dP/dt in the beat following the higher early diastolic mitral inflow (E) velocity, and lower dP/dt following the beats with lower E (Figure 2). Pulsed tissue Doppler at the mitral annulus demonstrated alternating systolic and diastolic tissue velocities. Peak systolic velocity alternated between 3 and 2 cm/min. The peak early diastolic velocity alternated between 8 and 6 cm/s (Figure 3). The patient was treated with intravenous diuretics and responded well. Angiotensin-converting enzyme inhibitor, a beta-blocker, and spironolactone were started. Echocardiography was repeated a few days after her admission and showed no change in ejection fraction or MR. However, there was no further clinical or echocardiographic evidence of pulsus alternans (systolic or diastolic). DiscussionPulsus alternans refers to alternating force of a palpable arterial pulse as a result of alternating LV stroke volumes (at constant R-R intervals), giving rise to beat-to-beat variability in systolic blood pressure. It is a known clinical sign of LV systolic dysfunction and is a marker of poor prognosis. Although it was described many years ago, the exact mechanism remains incompletely understood.1Edwards P. Cohen G.I. Both diastolic and systolic function alternate in pulsus alternans: a case report and review.J Am Soc Echocardiogr. 2003; 16: 695-697Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The proposed mechanisms have been of two major categories: contractile and hemodynamic.The contractile mechanism refers to alternating force of LV contraction. The role of calcium has been addressed with a possible role for alteration in the levels of intracellular calcium or the size of the calcium current.2McGaughey M.D. Maughan W.L. Sunagawa K. Sagawa K. Alternating contractility in pulsus alternans studied in the isolated canine heart.Circulation. 1985; 71: 357-362Crossref PubMed Scopus (51) Google ScholarThe hemodyanmic theory assumed beat-to-beat changes in preload conditions, resulting in beat-to-beat changes in systolic function, based on the Frank-Starling mechanism. More forceful beats result from increased preload, causing more complete emptying of the LV, such that the following beat starts with a smaller preload, thus, reducing the contractility. This was not accepted as the sole mechanism of pulsus alternans, as up until today variations in mitral inflow could not be demonstrated.3Lab M.J. Lee J.A. Changes in intracellular calcium during mechanical alternans in isolated ferret ventricular muscle.Circ Res. 1990; 66: 585-595Crossref PubMed Scopus (120) Google ScholarCostello et al4Costello D.L. Gaasch W.H. Criscitiello M.G. Echocardiographic examination in left ventricular alternans.Chest. 1979; 75: 72-75Crossref PubMed Scopus (6) Google Scholar described M-mode echocardiographic evaluation of pulsus alternans in a patient with cardiomyopathy after an acute viral illness. They were able to demonstrate LV systolic alternans, associated with early diastolic alternans of the mitral valvular motion, and alternating intensity of S3 gallop.Our case may help shed light on this problem. We demonstrated concomitant systolic and diastolic pulsus alternans, which disappeared as the patient’s hemodynamic status improved. We also demonstrated alternating tissue velocities (both in systole and diastole), further emphasizing the alternating myocardial mechanics in both phases of the cardiac cycle. Finally, we were able to demonstrate alternations in the LV contractility measured by the dP/dt (as calculated from the MR jet) with faster dP/dt in the beats with higher mitral inflow velocity, and lower dP/dt in the beats with lower mitral inflow velocity. This supports the theory of alternating loading conditions as a possible part of the mechanism of systolic pulsus alternans. Pulsus alternans refers to alternating force of a palpable arterial pulse as a result of alternating LV stroke volumes (at constant R-R intervals), giving rise to beat-to-beat variability in systolic blood pressure. It is a known clinical sign of LV systolic dysfunction and is a marker of poor prognosis. Although it was described many years ago, the exact mechanism remains incompletely understood.1Edwards P. Cohen G.I. Both diastolic and systolic function alternate in pulsus alternans: a case report and review.J Am Soc Echocardiogr. 2003; 16: 695-697Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar The proposed mechanisms have been of two major categories: contractile and hemodynamic. The contractile mechanism refers to alternating force of LV contraction. The role of calcium has been addressed with a possible role for alteration in the levels of intracellular calcium or the size of the calcium current.2McGaughey M.D. Maughan W.L. Sunagawa K. Sagawa K. Alternating contractility in pulsus alternans studied in the isolated canine heart.Circulation. 1985; 71: 357-362Crossref PubMed Scopus (51) Google Scholar The hemodyanmic theory assumed beat-to-beat changes in preload conditions, resulting in beat-to-beat changes in systolic function, based on the Frank-Starling mechanism. More forceful beats result from increased preload, causing more complete emptying of the LV, such that the following beat starts with a smaller preload, thus, reducing the contractility. This was not accepted as the sole mechanism of pulsus alternans, as up until today variations in mitral inflow could not be demonstrated.3Lab M.J. Lee J.A. Changes in intracellular calcium during mechanical alternans in isolated ferret ventricular muscle.Circ Res. 1990; 66: 585-595Crossref PubMed Scopus (120) Google Scholar Costello et al4Costello D.L. Gaasch W.H. Criscitiello M.G. Echocardiographic examination in left ventricular alternans.Chest. 1979; 75: 72-75Crossref PubMed Scopus (6) Google Scholar described M-mode echocardiographic evaluation of pulsus alternans in a patient with cardiomyopathy after an acute viral illness. They were able to demonstrate LV systolic alternans, associated with early diastolic alternans of the mitral valvular motion, and alternating intensity of S3 gallop. Our case may help shed light on this problem. We demonstrated concomitant systolic and diastolic pulsus alternans, which disappeared as the patient’s hemodynamic status improved. We also demonstrated alternating tissue velocities (both in systole and diastole), further emphasizing the alternating myocardial mechanics in both phases of the cardiac cycle. Finally, we were able to demonstrate alternations in the LV contractility measured by the dP/dt (as calculated from the MR jet) with faster dP/dt in the beats with higher mitral inflow velocity, and lower dP/dt in the beats with lower mitral inflow velocity. This supports the theory of alternating loading conditions as a possible part of the mechanism of systolic pulsus alternans." @default.
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• W2007760761 title "Systolic and Diastolic Pulsus Alternans in Severe Heart Failure" @default.
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