Cardiology Research and Practice

Cardiology Research and Practice / 2009 / Article

Case Report | Open Access

Volume 2009 |Article ID 703793 |

Param Vidwan, George A. Stouffer, "Biventricular Pulsus Alternans", Cardiology Research and Practice, vol. 2009, Article ID 703793, 3 pages, 2009.

Biventricular Pulsus Alternans

Academic Editor: Gerald Maurer
Received27 Apr 2009
Accepted27 Jun 2009
Published24 Sep 2009


Pulsus alternans is a rare hemodynamic condition characterized by beat-to-beat variability in systolic pressure. It is attributed to variations in stroke volume with alternate cardiac cycles and is typically seen in patients with advanced myopathic conditions. Left ventricular pulsus alternans is rare, and right ventricular pulsus alternans is even less common. There are only a few reports of biventricular pulsus alternans. We report the case of a 62-year-old female with a recent anterior wall myocardial infarction who had biventricular pulsus alternans at the time of cardiac catheterization.

1. Case Report

A 62-year-old female with diabetes mellitus and hypertension developed what she thought was the “flu” associated with orthopnea, shortness of breath, and chest pressure. She presented to her local physician 3 weeks later when the symptoms persisted and were accompanied by a 15–20 pound weight gain. Her BNP was markedly elevated and a chest X-ray showed cardiomegaly with bilateral pleural effusion. ECG and echocardiogram were consistent with a recent anterior wall myocardial infarction.

Cardiac catheterization after a 15 pound diuresis showed severely reduced left ventricular systolic function with an ejection fraction of 31%. Left heart filling pressures were elevated with a left ventricular end diastolic pressure of 26 mmHg and pulmonary capillary wedge pressure of 28 mmHg. She had severe disease of the mid left anterior descending coronary artery which was treated with placement of a drug-eluting stent. During the procedure, the patient had beat-to-beat alterations evident in aortic, pulmonary artery, left ventricular, and right ventricular pressures (Figure 1) in the absence of RR cycle length variation which is diagnostic of pulsus alternans.

In the nine months since her cardiac catheterization, she has had no recurrent heart failure, angina, or myocardial infarction. She remains active and has NYHA class II symptoms on a medical regimen that includes metoprolol (25 mg BID), quinapril (40 mg qD), and furosemide (20 mg qD).

2. Discussion

Pulsus alternans was originally described more than 100 years ago. It is a rare finding in the left ventricle and even less common in the right ventricle. The cause of pulsus alternans has not been clearly delineated, and there is some speculation that different mechanisms may play a role dependent on the patient. One proposed mechanism is beat-to-beat alternations in stroke volume due to variation in preload and contractility. Impaired systolic contraction of a failing ventricle reduces stroke volume which then results in elevated end diastolic volume for the next contraction. Elevated left ventricular stretch results in increased stroke volume and therefore increased systolic pressure on the next beat [1]. Another proposed mechanism for the physiology of pulsus alternans involves abnormal calcium handling by cardiac myocytes [2]. In support of this hypothesis, cardiac-specific overexpression of calsequestrin, a major storage protein for calcium in the sarcoplasmic reticulum, resulted in significant decreases in contractile parameters and intracellular Ca++ transients and the development of pulsus alternans in a mouse model [3].

Severe left ventricular systolic dysfunction is the primary cause of pulsus alternans but other causes have been reported in humans including aortic stenosis [4, 5], hypertrophic obstructive cardiomyopathy [6], mitral stenosis [7], prosthetic valve dysfunction [8], and during dobutamine infusion [9, 10]. Right ventricular pulsus alternans has been reported in cases with severe right ventricular failure, primary pulmonary hypertension, prosthetic mitral valve thrombosis, diastolic or systolic left ventricular dysfunction, reactive airway disease, pulmonary embolus, and mitral stenosis [1113]. Biventricular pulsus alternans has been described in a patient with severe left ventricular dysfunction and left anterior descending coronary artery disease [14], similar to the current case.


  1. M. J. Lab and W. A. Seed, “Pulsus alternans,” Cardiovascular Research, vol. 27, no. 8, pp. 1407–1412, 1993. View at: Google Scholar
  2. G. Kotsanas, S. M. Holroyd, R. Young, and C. L. Gibbs, “Mechanisms contributing to pulsus alternans in pressure-overload cardiac hypertrophy,” American Journal of Physiology, vol. 271, no. 6, pp. H2490–H2500, 1996. View at: Google Scholar
  3. A. G. Schmidt, V. J. Kadambi, N. Ball et al., “Cardiac-specific overexpression of calsequestrin results in left ventricular hypertrophy, depressed force-frequency relation and pulsus alternans in vivo,” Journal of Molecular and Cellular Cardiology, vol. 32, no. 9, pp. 1735–1744, 2000. View at: Publisher Site | Google Scholar
  4. R. M. Gagnon and D. Doyle, “Transient left ventricular pulsus alternans in severe aortic valve disease,” Canadian Journal of Cardiology, vol. 4, no. 5, pp. 217–218, 1988. View at: Google Scholar
  5. W. K. Laskey, S. M. St. John, W. J. Untereher, J. L. Martin, J. W. Hirshfeld Jr., and N. Reichek, “Mechanics of pulsus alternans in aortic valve stenosis,” American Journal of Cardiology, vol. 52, no. 7, pp. 809–812, 1983. View at: Google Scholar
  6. R. O. Cannon III, W. H. Schenke, R. O. Bonow, M. B. Leon, and D. R. Rosing, “Left ventricular pulsus alternans in patients with hypertrophic cardiomyopathy and severe obstruction to left ventricular outflow,” Circulation, vol. 73, no. 2, pp. 276–285, 1986. View at: Google Scholar
  7. M. J. Kern, “Hemodynamic rounds series II: mitral stenosis and pulsus alternans,” Catheterization and Cardiovascular Diagnosis, vol. 43, no. 3, pp. 313–317, 1998. View at: Publisher Site | Google Scholar
  8. R. T. Jortner, B. Rafaelof, P. A. Tunick, and I. Kronzon, “Pulsus alternans as a sign of prosthetic valve dysfunction,” American Heart Journal, vol. 127, no. 1, pp. 221–224, 1994. View at: Publisher Site | Google Scholar
  9. M. Kodama, K. Kato, S. Hirono et al., “Linkage between mechanical and electrical alternans in patients with chronic heart failure,” Journal of Cardiovascular Electrophysiology, vol. 15, no. 3, pp. 295–299, 2004. View at: Google Scholar
  10. J. H. L. Kahn, M. R. Starling, and M. A. Supiano, “Transient dobutamine-mediated pulsus alternans,” Canadian Journal of Cardiology, vol. 17, no. 2, pp. 203–205, 2001. View at: Google Scholar
  11. J. W. Askew and R. W. Lee, “Isolated pulmonary arterial pulsus alternans secondary to pulmonary hypertension,” Clinical Cardiology, vol. 27, p. 358, 2004. View at: Google Scholar
  12. A. Abu-Ful, R. Ilia, and Y. Henkin, “Right-sided pulsus alternans in prosthetic mitral valve thrombosis,” Journal of Invasive Cardiology, vol. 16, no. 4, pp. 213–214, 2004. View at: Google Scholar
  13. R. Ilia, A. Abu-Ful, J. M. Weinstein, and M. Merkin, “Right-sided pulsus alternans in diastolic left ventricular dysfunction,” Catheterization and Cardiovascular Interventions, vol. 47, no. 3, pp. 336–339, 1999. View at: Google Scholar
  14. A. D. Michaels, A. E. M. Browne, P. Varghese, and T. M. Chou, “Intracoronary measurement of pulsus alternans,” Catheterization and Cardiovascular Interventions, vol. 51, no. 3, pp. 335–338, 2000. View at: Publisher Site | Google Scholar

Copyright © 2009 Param Vidwan and George A. Stouffer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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