Right-sided pulsus alternans in diastolic left ventricular dysfunction

Comparison of patients with pulmonary arterial hypertension with versus without right-sided mechanical alternans

The clinical implications of mechanical alternans in patients with pulmonary arterial hypertension (PAH) remain unknown. In this study, the prevalence, characteristics, and prognostic implications of mechanical alternans in patients with PAH were investigated. Thirty-two consecutive patients with PAH confirmed by cardiac catheterization from 2000 to 2010 were included in this cohort study. During cardiac catheterization, 8 patients (25%) showed mechanical alternans at rest. All alternans were detected in the right ventricle and pulmonary trunk. Serum level of brain natriuretic peptide (584 ± 177 vs 238 ± 252 pg/ml, p = 0.001), World Health Organization functional class (3.5 ± 0.5 vs 2.9 ± 0.4, p = 0.02), mean pulmonary arterial pressure (59 ± 10 vs 47 ± 18 mm Hg, p = 0.03), mean right atrial pressure (10 ± 4 vs 5 ± 4 mm Hg, p = 0.01), right ventricular end-diastolic pressure (15 ± 5 vs 9 ± 5 mm Hg, p = 0.01), and heart rate at catheterization (96 ± 17 vs 70 ± 11 beats/min, p = 0.003) were significantly higher in patients with alternans than in those without. Twelve-month mortality of patients with alternans was higher than in patients without alternans (p = 0.03): the 12-month survival rate after cardiac catheterization was 37% for the alternans group and 75% for the group without alternans. In conclusion, isolated right-sided mechanical alternans is not an uncommon event in patients with PAH. The existence of alternans is associated with the severity of PAH and right ventricular dysfunction and implies a poor prognosis in the short term.

Biventricular pulsus alternans

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.

Das Herz bei arterieller Hypertonie

The term hypertensive heart disease covers the entities of left ventricular hypertrophy, microangiopathy and endothelial dysfunction resulting in diastolic and systolic dysfunction, arrhythmias and increased cardiovascular risk. From the pathophysiological point of view, this is caused by the hypertrophy of cardiac myocytes, interstitial fibrosis and media hypertrophy of the arterioles. Microangiopathy can be diagnosed as the earliest sign of hypertensive heart disease, with diastolic dysfunction also being found as an early change. In further persisting arterial hypertension left ventricular hypertrophy develops (often asymmetric) and later a systolic dysfunction. Clinically, the patients suffer from angina pectoris, dyspnea and rhythm disorders. Left ventricular hypertrophy is associated with an increased risk of malignant ventricular arrhythmias. Thus, the main therapeutic principle should be antihypertensive therapy with the goal of regression of hypertrophy leading to decreased mortality risk.

Intracoronary measurement of pulsus alternans

Pulsus alternans is typically found in patients with left ventricular systolic dysfunction. We describe a woman with biventricular systolic dysfunction and pulsus alternans in the right ventricle, pulmonary artery, and aorta. Coronary angiography revealed an intermediate stenosis in the proximal left anterior descending (LAD) coronary artery. Pulsus alternans was demonstrated in the mid LAD using a 0.014" guidewire-mounted pressure sensor. An abnormal fractional flow reserve was measured in the LAD. Cathet. Cardiovasc. Intervent. 51:335-338, 2000.