Total pulsus alternans – pulsus alternans totalis

Total pulsus alternans – pulsus alternans totalis

Total pulsus alternans or pulsus alternans totalis occurs when the force of contraction is so low in alternating beats that the aortic valve fails to open. It can be documented by simultaneous pulse and ECG recording.

In an interesting case report, ECG monitor showed a rate of 160 per minute due to atrial tachycardia while the simultaneous pulse tracing showed a pulse rate of 80 per minute [1]. The patient had paroxysmal ectopic atrial tachycardia. There was tachycardiomyopathy due to incessant tachycardia, producing left ventricular dysfunction. Echocardiogram documented alternating excursions of aortic and mitral valves. Outflow velocities also showed alternans.

Mitral opening alternans was despite similar left ventricular wall thickening, and authors suggested changes in mitral opening and ventricular filling contributed to the alternans. Pulsus alternans was abolished after successful radiofrequency catheter ablation of the atrial tachycardia. Echocardiography demonstrated normal opening of aortic and mitral valves with normal flow velocities after successful catheter ablation of atrial tachycardia.

Similar extreme pulsus alternans has been described in a child with left ventricular dysfunction secondary to hypertension [2]. Doppler of aortic flow showed halving of pulse frequency compared to the ECG like a 2:1 electromechanical dissociation. The alternans disappeared after afterload reduction with nitroprusside.

References

1. Lu B, Roberts B, Sadaniantz A. Ineffective diastolic filling in tachycardia-induced cardiomyopathy with total pulsus alternans. J Am Soc Echocardiogr. 1997 Jan-Feb;10(1):88-92.
2. Pipitone S, Giudice G, Giuffrè M, Sperandeo V. Extreme pulsus alternans with P wave alternans in a child. Pediatr Cardiol. 2002 Sep-Oct;23(5):557-61.