Case 35 Two to one ventricular electrical alternans associated with uremic pericardial effusion

We analyze two mathematical models of Rigney and Goldberger (14) of heart swinging in large pericardial effusions. Both models represent the torques due to the outflow of blood from the heart. The first assumes that the duration of systole does not vary with heart rate (in beats/min), whereas the second assumes that it varies linearly with heart rate. We examine the motion of the heart for heart rates between 50 and 200 and for a range of initial positions and velocities. Both models predict that the heart swings once every other beat (2:1 swinging, giving rise to electrical alternans) in a discrete range of heart rates and swings once per beat otherwise; both models explain the appearance and disappearance of 2:1 swinging mathematically. The first model predicts a rate range from 105 to 116 for the occurrence of 2:1 swinging. The second model predicts the same qualitative behavior but with 2:1 swinging occurring at heart rates between 88 and 119, which agrees well with published clinical data showing 2:1 swinging at heart rates between 90 and 144. We describe an analysis program for ordinary differential equations that analyzed the models quickly and automatically.

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Electrical alternans: Mechanism in pericardial effusion

American Heart Journal ◽

10.1016/0002-8703(72)90035-x ◽

1972 ◽

Vol 83 (4) ◽

pp. 459-463 ◽

Cited By ~ 45

Author(s):

Bruce W. Usher ◽

Richard L. Popp

Keyword(s):

Pericardial Effusion ◽

Electrical Alternans

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Diagnostic echocardiography in an unstable intensive care patient

Echo Research and Practice ◽

10.1530/erp-14-0040 ◽

2015 ◽

Vol 2 (1) ◽

pp. K11-K16 ◽

Cited By ~ 2

Author(s):

R Gray ◽

F Baldwin ◽

S Bruemmer-Smith

Keyword(s):

Intensive Care ◽

Pericardial Effusion ◽

Aortic Dissection ◽

Cardiac Tamponade ◽

Type A ◽

List Type ◽

Type B ◽

Type B Aortic Dissection ◽

Type A Aortic Dissection ◽

Electrical Alternans

SummaryA previously fit and well 57-year-old gentleman who had recently undergone a colonoscopy and biopsy of a polyp presented with a 4-day history of progressive breathlessness and abdominal discomfort. The day after admission, he became haemodynamically unstable, developed ischaemic legs and suffered a brief cardiac arrest. Blood tests demonstrated a coagulopathy and hypoglycaemia. Continued haemodynamic instability post-arrest and clinical findings of high right-sided heart pressures were investigated by bedside screening echocardiogram. This demonstrated a massive pericardial effusion causing tamponade of the right ventricle. Heavily blood stained pericardial fluid was drained, with marked improvement in haemodynamic stability. Retrospective review of the admission-electrocardiogram (ECG) and chest X-ray demonstrated electrical alternans and cardiac enlargement. The differential diagnosis included bowel malignancy causing a haemorrhagic metastatic pericardial effusion and a type A aortic dissection. Therefore a computerised tomography (CT) scan of chest, abdomen, pelvis and aorta was performed. This was negative for disseminated malignancy and showed a type B aortic dissection, but was inconclusive for a type A aortic dissection. A subsequent transoesophageal echocardiogram confirmed the diagnosis of type B dissection and ruled out a type A dissection. The histology of the colonic polyp was negative for malignancy, but it was subsequently discovered that the patient had metastatic adenocarcinoma from a primary lung cancer diagnosed from pleural fluid cytology. With hindsight the presenting clinical picture was of type B aortic dissection with concurrent but not directly related pericardial tamponade.Learning pointsBasic echocardiography skills are increasingly being used acutely by physicians' as part of resuscitative care in intensive care unit (ICU) patients.The availability of expert skills in transoesophageal echocardiography are essential in ICU, as demonstrated in this case, where it was needed for discriminating between sub types of aortic dissection.Cardiac tamponade is a clinical diagnosis, although the presence of electrical alternans on an ECG with associated tachycardia is highly suggestive of cardiac tamponade.

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Electrical alternans occurring in a case with pericardial effusion

American Heart Journal ◽

10.1016/s0002-8703(38)90038-9 ◽

1938 ◽

Vol 15 (1) ◽

pp. 100-106 ◽

Cited By ~ 7

Author(s):

L. Feldman

Keyword(s):

Pericardial Effusion ◽

Electrical Alternans

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ICD-Electrode-Perforation of the Right Ventricle to the Pericardium with and without Pericardial Effusion

Radiology and Medical Diagnostic Imaging ◽

10.31487/j.rdi.2020.02.09 ◽

2020 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Line Lisbeth Olesen ◽

Line Lisbeth Olesen

Keyword(s):

Pericardial Effusion ◽

Right Ventricle ◽

Low Voltage ◽

X Ray ◽

First Case ◽

Difficult Time ◽

Chest X Ray ◽

Cardiac Silhouette ◽

The Right ◽

Electrical Alternans

Two cases are described of iatrogenic traumatic perforation of an ICD electrode through the myocardium in the right ventricle and to the pericardium. The diagnostic gold standard gated CT was not necessary in either case. In the first case the lead insertion was difficult, time-consuming, and complicated by the PostCardiac Injury Syndrome and a slowly accumulating hemorrhagic pericardial effusion causing cardiac tamponade, diagnosed by the clinical picture, elevated CRP, ECG with low voltage and electrical alternans, chest X-ray revealing enlarged cardiac silhouette and echocardiography a large effusion, treated with pericardiocentesis and drainage. In the other case there was painful pericardial irritation and extracardiac pacing and ICD failure with loss of capture, no diagnostic changes in ECG, chest X-ray, and echocardiography; diagnosed by fluoroscopy during replacement at the lead, which went without complications and without pericardial effusion.

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Subtle electrical alternans in a large pericardial effusion with tamponade

Journal of Emergency Medicine ◽

10.1016/s0736-4679(97)00023-1 ◽

1997 ◽

Vol 15 (3) ◽

pp. 371-372

Author(s):

David E. Slattery ◽

David W. Dickerson ◽

Charles V. Pollack

Keyword(s):

Pericardial Effusion ◽

Large Pericardial Effusion ◽

Electrical Alternans

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