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Pulsus Alternans After Aortic Valve Replacement Letters to Editor RT-3D-TEE has ability to demonstrate tumor REFERENCES characteristics in its en-face view, which may be more 1. Asch FM, Bieganski SP, Panza JA, Weissman NJ. Real-time 3-dimensional convincingly appreciated by the operating surgeon echocardiography evaluation of intracardiac masses. Echocardiography than the 2D imaging. It facilitates understanding of 2006;23:218-24. attachments of the myxoma to different parts of the 2. Mehmood F, Nanda NC, Vengala S, Winokur TS, Dod HS, Frans E, et al. Live three-dimensional transthoracic echocardiographic assessment of LA; structural damage to the mitral valve; and degree left atrial tumors. Echocardiography 2005;22:137-43. of free space available for blood flow inside the LA and 3. Culp WC Jr, Ball TR, Armstrong CS, Reiter CG, Johnston WE. Three- across the mitral valve. dimensional transesophageal echocardiographic imaging and volumetry of giant left atrial myxomas. J Cardiothorac Vasc Anesth 2009;23:66-8. Isolated echolucent areas observed on live RT-3D-TEE are consistent with hemorrhage/necrosis in the tumor mass. These findings are typical of a myxoma and the Pulsus alternans after areas of echolucencies correspond to tumor hemorrhages and/or necrosis found on pathological examination of aortic valve replacement: the resected myxomas.[2] This echocardiographic feature Intraoperative recognition of a LA myxoma may be utilized to differentiate it from a hemangioma, which comprises much more extensive and role of TEE and closely packed echolucencies practically involving the whole extent of the tumor mass with relatively DOI:10.4103/0971-9784.62932 sparse solid tissue. Virtual cropping at different sequential levels in the three-dimensional data set Sir, enabled us to demonstrate echolucencies, which was Pulsus alternans (P ) is beat-to-beat variability in not possible on 2D examination. ALT systolic blood pressure, which occurs due to alternating stroke volumes of left ventricle (LV). It is known Major limitations of 2D echocardiography (both to be associated with severe left ventricular TTE and TEE) in examining the LA myxoma are dysfunction.[1,2] Although a large number of factors difficulty in evaluating it from all possible planes and have been implicated in induction of PALT in the operator dependent interpretations of the findings. intraoperative period, it has not been reported to 2DE measurements underestimate the true maximum occur as a result of cardiac handling after aortic valve diameter and tumor size of irregularly shaped replacement (AVR). A 33-year-old male patient was intracardiac tumors like LA myxoma. Although, operated for AVR on cardiopulmonary bypass (CPB). there are reports suggesting utility of RT-3D-TEE in Preoperative transthoracic echocardiography (TTE) volumetric assessment of LA myxomas;[2,3] it has not revealed a dilated left ventricle and severe aortic yet been validated like RT-3d-TTE. Virtual volume regurgitation (AR) with left ventricular ejection fraction estimated using RT-3D-TEE in those reported cases of 25%. After establishment of CPB and cardioplegic arrest, the native aortic valve was excised and replaced was comparable to the volume measured with the with a 23-mm bileaflet prosthetic valve (St. Jude gold standard water displacement. The size of an Medical, USA). The patient was weaned from CPB using intracardiac mass (vegetation, tumor, or thrombus) 0.1 mcg/ kg/ minute of epinephrine infusion. A stable is an important predictor for embolic events and for hemodynamic condition was maintained in the period response to treatment. immediately after weaning. TEE examination revealed a global LV hypocontractility with the left ventricular In summary, the intraoperative RT-3D-TEE has a fractional area change of 24% [video 1]. The AV potential role to play in the assessment of LA myxoma. prosthesis worked satisfactorily without any evidence of a paravalvular leak [video 2]. As the heart rate Shrinivas Gadhinglajkar, Rupa Sreedhar decreased to 60/ minute from 84/ minute after cardiac Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical decannulation, atrial pacing (AAI) was started at a rate of Sciences and Technology, Trivandrum, Kerala, India. 90/ minute. When the surgeon started retracting the heart Address for correspondence: Dr. Shrinivas Gadhinglajkar during surgical hemostasis, the systolic BP decreased from Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India. Video available at www.annals.in E- mail: [email protected] Annals of Cardiac Anaesthesia Vol. 13:2 May-Aug-2010 181 Letters to Editor 120 mmHg to 70 mmHg. When the heart manipulations Intraoperative transaortic Doppler profile characteristics ceased, the PALT was observed on the monitoring screen of PALT are rarely described in the literature. Contractile with a systolic pressure difference of 30 mmHg between and hemodynamic mechanisms have been proposed to two consecutive beats [figure 1], which lasted for about explain the phenomenon of the PALT.[1,2] The contractile two minutes. The continuous wave Doppler (CWD) tracing mechanism refers to incomplete recovery of contractile recorded across the prosthetic valve in deep transgastric cells, leading to an alternating force of left ventricular long axis (DTG-LAX) view revealed velocity time integrals contraction. The hemodynamic theory [3] is based on (VTI)s of large and small sizes alternating with each other three factors affecting preloading conditions or left [figure 2C, 3 pulsus alternans]. A regular pulse trace ventricular end-diastolic volume (LVEDV): appeared with similar paced rhythm after two minutes, which was accompanied with a regular systolic ejection 1. Duration of the diastole: The diastolic filling time [figure 2A]. We also observed a transient increase followed of consecutive beats determines the end-diastolic by a progressive decrease in the size of VTIs during volume. As the diastolic interval preceding a smaller positive pressure breathing, when the left atrial pressure beat is short, the resultant LVEDV would be lesser was 3 mmHg [figure 2B]. The surgeon was requested to than that of a larger beat, which succeeds a longer minimize the phenomenon of alternans as it was seen repeatedly on cardiac manipulation. The alternans did not occur after the closure of sternum. Tracheal extubation Table 1: Intervals for components of different doppler beats was carried postoperatively after six hours of elective Period on a CWD Regular Larger Smaller ventilation. His postoperative recovery was uneventful. profile beat beat of beat of pulsus pulsus We viewed the AV CWD profile off-line and measured RR alternans alternans intervals and atrial pacing signal-to-R wave intervals on Interval between ECG 0.661 0.661 0.661 consecutive R waves ECG, which remained constant during successive cardiac (seconds) cycles of regular beats and beats during PALT [figures Interval between ECG 0.229 0.229 0.229 3, 4]. CWD cardiac cycle for a beat was considered as pacing signal to R wave (seconds) interval between onsets of systolic ejection of that beat Duration of systolic 0.223 0.229 0.216 and the next beat. The duration of CWD cardiac cycles ejection (seconds) also was constant for regular and PALT beats. The systolic Interval between 0.439 0.432 0.445 ejection phase lasted longer in the bigger beat of PALT end-systole of a beat than the smaller one. On the contrary, the remaining to commencement of systole of a succeeding cardiac cycle interval was longer for the smaller beat beat (seconds) than the larger beat [figure 4]. Characteristically, the Duration of Doppler 0.662 0.661 0.661 period between the AV prosthetic end-systolic excursion cardiac cycle (seconds) preceding and following a large beat was longer than Duration between AV 0.661 0.675 0.648 that between a smaller beat. Their addition, however, excursion preceding was equal to the summation of the period over two and following a beat (seconds) consecutive cardiac cycles [figure 3B]. The Doppler CWD: continuous wave Doppler intervals of different beats are summarized in table 1. Figure 1: A snapshot from the monitoring screen showing PALT with a large beat Figure 2: Transaortic CWD flow profile is recorded during three separate events. (white arrow) and a small beat (black arrow) alternating with each other. ECG A: VTIs of same magnitude are seen during a regular cardiac beating. The white is showing cardiac rhythm after atrial pacing (White arrow head). The atrium arrow and white arrow head are indicating beginning of systolic ejection and was paced at a rate of 90/ minute. Abbreviations: - PALT: pulsus alternans; VTI: end-systole respectively. B: The VTIs are becoming progressively smaller in size velocity-time integral; CWD: continuous wave Doppler during a positive pressure breath. C: PALT indicated by alternating in size VTIs. 182 Annals of Cardiac Anaesthesia Vol. 13:2 May-Aug-2010 Letters to Editor Figure 3: Time-intervals are recorded off-line from both the CWD flow profile and ECG. Regular: During regular cardiac ejection, the intervals A and B (aortic valve Figure 4: CWD cardiac cycles for different beats, which constituted an ejection systolic excursions) are equal to the intervals E and F (RR intervals). Intervals systolic interval and rest of the interval (interval of diastolic phase + interval C and D (atrial pacing signal-to-R wave) are remaining constant. PALT: In PALT, of isovolemic contraction phase), are seen in the figure. The ejection systolic the intervals G and H (atrial pacing signal-to-R wave) and intervals K and L intervals for a regular beat, a smaller beat of PALT and a larger beat of PALT (R-R intervals) are constant. The period I is less than period J (prosthetic valve are intervals E, A and C respectively. Rests of the intervals for these three types end-systolic excursions related to smaller and larger beats); however, Period I of beats are intervals F, B and D respectively. The duration of a CWD cardiac + J = Period K + L.
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