Pulsus alternans: a visual clue to a grave disorder!

Description

A 15-year-old, previously healthy teenager who had fatigue, shortness of breath, vomiting, chest discomfort, lower extremity oedema and inability to lay flat for 3 weeks prior to her initial presentation. She was warm, well perfused with alternating strong and weak central as well as peripheral pulses and laterally displaced cardiac impulse. Her monitoring showed visual evidence of 'pulsus alternans'—alternating low and high amplitude waveforms on the arterial waveform and plethysmography (figure 1). Her echocardiography showed severely depressed left ventricular function with ejection fraction of 15%. In addition, sinus tachycardia and varying capnography waveform supported the diagnosis. She gradually worsened requiring intubation and mechanical ventilation. She was diagnosed with primary cardiomyopathy. She underwent the placement of ventricular assist device and now awaits heart transplant.

Figure 1

Monitor showing (A) sinus tachycardia on telemetry. (B) Plethysmography showing alternating low and high amplitude waves as indicated...

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