Case Report
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Clin Cases. Aug 16, 2013; 1(5): 162-165
Published online Aug 16, 2013. doi: 10.12998/wjcc.v1.i5.162
Biventricular pulsus alternans: An echocardiographic finding in patient with pulmonary embolism
Tin Nguyen, Long-Bao Cao, Minh Tran, Assad Movahed
Tin Nguyen, Long-Bao Cao, Minh Tran, Assad Movahed, Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, Greenville, NC 27834, United States
Author contributions: Nguyen T, Cao LB, Tran M and Movahed A contributed to the manuscript writing and revision.
Supported by The “East Carolina Heart Institute”
Correspondence to: Assad Movahed, MD, Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, 115 Heart Drive, Mail Stop 651, Greenville, NC 27834, United States. movaheda@ecu.edu
Telephone: +1-832-3731447 Fax: +1-252-7447724
Received: June 11, 2013
Revised: July 7, 2013
Accepted: July 17, 2013
Published online: August 16, 2013
Processing time: 56 Days and 13.2 Hours
Abstract

Pulsus alternans is characterized by regular rhythm with beat-to-beat alternation of systolic pressures. Left ventricular alternans is usually found in severe left ventricular dysfunction due to cardiomyopathy, coronary artery disease, systemic hypertension, and aortic stenosis. Right ventricular alternans is usually associated with left ventricular alternans, right ventricular dysfunction, pulmonary embolism, and pulmonary hypertension. Biventricular alternans is rare and associated with severe left ventricular dysfunction and left anterior descending coronary artery disease. The exact mechanism of pulsus alternans has not been clearly delineated, and it has been remained a subject of investigation and conjecture since the nineteenth century. Two fundamental mechanisms have been proposed to explain ventricular alteration. The first, based on the Frank-Starling mechanism, proposes beat-to-beat alteration in end-diastolic volume accounted for the alternating contractile force. The second proposed mechanism which explains the physiology of pulsus alternans involves the abnormal calcium handling by cardiac myocytes. To the best of our knowledge, biventricular alternans in pulmonary embolism has not been previously reported in the medical literature. We present and discuss the mechanisms of pulsus alternans and its clinical implications.

Keywords: Pulsus alternans; Biventricular alternans; Pulmonary embolism

Core tip: Biventricular pulsus alternans is a rare phenomenon and has only been described in few cases of severe left ventricle systolic dysfunctions and left anterior descending coronary artery disease. Pulsus alternans is an ominous sign that suggests severe heart failure; early recognition can aid in appropriate management and intervention, which may change patient outcome.