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Electrical Alternans in Cardiac Tamponade Andreas P Henry Ford Hospital Medical Journal Volume 21 | Number 4 Article 3 12-1973 Electrical Alternans in Cardiac Tamponade Andreas P. Niarchos Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Niarchos, Andreas P. (1973) "Electrical Alternans in Cardiac Tamponade," Henry Ford Hospital Medical Journal : Vol. 21 : No. 4 , 169-180. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol21/iss4/3 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. FHenry Ford FHosp. Med. Journal Vol. 21, No. 4, 1973 Electrical Alternans in Cardiac Tamponade Andreas P. Niarchos, M.D.,* tLECTRICAL alternans has been de­ fined as an alternation of the configura­ tion of the electrocardiographic com­ plexes arising from the same pacemaker and independent of periodic extracardiac Of nine patients with pericardial effusion phenomena.' This electrocardiographic due to various causes, four developed cardiac abnormality was initially observed in the tamponade. Electrical alternans was present In laboratory by Herring in 1909,^ and first all four, being total in three, and ventricular in one. From the diagnostic point of view, the reported clinically the year after by alternans corresponded with the clinical diag­ Lewis.^ Other early reports were those of nosis of cardiac tamponade and the radiologi­ Hamburger, Katz and Saphir," and of cal signs of a large pericardial effusion. The Brody and Rossman.^ The literature on pericardial fluid was hemorrhagic in three pa­ the subject up to 1955 has been reviewed tients and transudate (hydropericardium) in the fourth. In two patients alternans was pres­ by McGregor and Baskind.'' ent with heart rates below 100 per minute. Apart from the exact (1:1) type of electrical Any electrocardiographic complex can alternans, three new types are described; a 2:1, exhibit alternation, the P wave rarely,''" 3:1 and a varying type. It is concluded that a) electrical alternans associated with pericardial the QRS complex,* or the T wave effusion is strongly suggestive of impending or alone,'"'^ or all three complexes can al­ established cardiac tamponade, and b) electri­ ternate simultaneously, when the cal alternans is produced when the heart is phenomenon is called total electrical oscillating within the pericardial sac distended by fluid with a frequency equal to one-half alternans.Although ventricular and (exact alternans), one-third (2.-7 alternans) and total electrical alternans are not very one-fourth (3:1 alternans) ofthe heart rate. The common they are of clinical interest be­ etiology and mechanism of electrical alternans cause they occur primarily in association are discussed. with massive pericardial effusion and cardiac tamponade.',2,6,11,14-1' 8 Two theories have been suggested to explain the mechanism of electrical al­ ternans. One attributes the alternation of the electrocardiographic complexes to alternating conduction within the 'Formerly Medical Registrar, Royal Southern myocardium.' The other theory main­ Hospital, Liverpool, England. Presently fellow. tains that the conduction within the Section on Hypertension, Division of myocardium during alternans remains Metabolic Diseases. unchanged, but that a cyclic motion of Address reprint request to author c/o Henry the heart within a distended pericardial Ford Hospital, 2799 West Grand Boulevard, sac accounts for the alternating elec­ Detroit, Ml 48202 trocardiographic pattern.^''""^° This 169 Niarchos TABLE I. DIAGNOSIS AND OUTCOME IN THE 9 PATIENTS Case No. Sex/Age Clinical Type of fluid Electrical Primary Outcome diagnosis and means of alternans Disease confirmation 1 M 5? Tamponade Hemorrhagic Total Acute Survived pericardio­ myocardial centesis infarction 2 M 55 Tamponade Hemorrhagic Total Carcinoma Died pericardio­ L. bronchus centesis and invading necropsy pericardium 3 F 62 Tamponade Hemorrhagic Total Secondary Died pericardio­ carcinomatous centesis and pericarditis, necropsy primary unknown 4 36 Large effusion Hydropericardium Ventricular Malabsorption Survived Albumin/globulin due to celiac ratio = 0.6/1 disease (See text) 5 M 53 Effusion Not known Absent Benign Survived pericarditis 6 M 72 Effusion Hemorrhagic Absent Acute Died Necropsy myocardial infarction 7 M 63 Effusion Hemorrhagic Absent Acute Died Necropsy myocardial infarction 8 M 37 Effusion Not known Absent Uremia Survived 9 M 62 Effusion Hydropericardium Absent Extensive Survived Low albumin/ burns globulin ratio paper reports the findings of a clinical, diagnosis of celiac disease was confirmed radiological and electrocardiographic by jejunal biopsy. All but two patients study in patients with pericardial effusion were treated in an intensive therapy unit, and tamponade associated with total and under continuous electrocardiographic ventricular electrical alternans, in whom monitoring. All patients had serial elec­ the confirmation of the mechanical trocardiograms and chest radiographs. theory ofthe genesis of alternans is based The cardiothoracic ratio and cardiac on electrocardiographic data. silhouette volume were estimated from data obtained from radiographs (taken Patients and Methods from a distance of six feet with the patient Nine patients were studied, eight standing), as described by Glover, Bax­ males and one female; their age ranged ley, and Dodge.^' In addition the diag­ from 36 to 72 years. Pericardial effusion nosis of large pericardial effusion was with tamponade was diagnosed in four, confirmed by radioisotope heart scans in and pericardial effusion without tam­ two patients (Figure 1), serial phonocar- ponade in five (Table I). The various diag­ diograms (Figure 2), and cardiac noses were established clinically and by catheterization in one (case 4), and by the appropriate laboratory tests. The pericardiocentesis in three patients 170 Electrical Alternans in Cardiac Tamponade Figure 1, Case 2 Radioisotope heart scan showing large pericardial effusion mainly anterioHy. (Table I). Necropsy was performed in TABLE II. MAIN CLINICAL FINDINGS four of the cases. The incidence of clin­ IN THE 9 PATIENTS ical, electrocardiographic and radiologi­ cal findings was compared between the Number of patients tamponade and simple effusion groups. Findings Tamponade Effusion The radiological findings were statisti­ Pulsus paradoxus 2 Nil cally analysed using the Student's t test. Sinus arrhythmia 4 4 Two patients from this series (cases 6 and Sinus tachycardia 2 4 7) have been briefly described (heart rate > 100/min.) Raised JVP 4 4 previously." Hypotension 4 1 (systolic BP < 100 mmHg) Results Dyspnea 4 1 Absent heart sounds 2 Nil Clinical Findings Faint heart sounds 2 1 The main clinical findings in both Pericardial friction rub 1 3 Absent apex beat 4 groups are listed in Table II. Pericar- — 171 Niarchos Figure 2, Case 4 Phonocardiogram; a third heart sound is present. diocentesis relieved the symptoms in although showing initial improvement, cases 1,2 and 3. Furosemide was given to died later from recurrent cardiac tam­ the patient in Case 1 after the pericar­ ponade. The patient with celiac disease diocentesis and his condition improved was treated from the start with gradually. The second and third patients, Furosemide with considerable improve- TABLE III. RESULTS OF CARDIAC CATHETERIZATION IN CASE 4 Position of catheter tip Pressure (mmHg) Left ventricle 95/10, early diastole:8, at "a" wave=20 Left atrium a=20, 0=21, x=10, V = 15, y=8, mean=9 Left pulmonary artery wedge a=20, x=9, V=14, y=10, mean = 13 Pulmonary artery 32/16, mean=27 Right ventricle 32/5, early diastole=5, at "a" wave=18 Right atrium a=15, x=10, V=16, y=10, mean=13 Blood oxygen saturation: Normal 172 Electrical Alternans in Cardiac Tamponade ment. Cardiac catheterization one week later showed cardiac restriction with ele­ vated end-diastolic pressures in all car­ diac chambers (Table HI). He was given a gluten-free diet and the pericardial effu­ HEART sion was reduced when his plasma pro­ teins returned to normal. Rir-hi Electrocardiographic Findings Lead Sinus arrhythmia and low voltage were V, present in all patients with cardiac tam­ ponade, and in most patients with pericardial effusion. Electrical alternans, however, was present only in the four patients with tamponade. The alternans was total (P-QRS-T) in the first three cases (Figures 3, 4 and 5), and ventricular (QRS) in the fourth. In the first case it was only seen in leads II, and AVF. In the second it was present in all leads, while in the third and fourth case it was better seen in lead Vi. The alternans was not constant in the fourth case. The alternating com­ plexes varied in height from complex to complex even in the same lead (Figure 3), the difference being greater in the right (Vi,V2) and left (V^) chest leads. The elec­ trical alternans disappeared in cases 1, 2 and 3 after aspiration of 30, 65 and 670 V4 mis of pericardial fluid respectively (Fig­ ures 4 and 5), and after treatment with Furosemide in the fourth patient, but the tachycardia persisted in case 3 (Figure 4). The pericardial fluid was hemorrhagic in all, and malignant cells were identified in the fluid removed from the case 3 patient. During reaccumulation ofthe pericardial effusion in cases 2 and 3, several types of 3«5 5.0 3.5 alternans were seen (Table IV). Loft Middle Ri^'-ht The heart and alternans rate and the various electrocardiographic types of al­ ternans before pericardial aspiration are shown in Table IV. A heart rate above 100 per minute was present in two patients 7 n on three occasions, while in the rest of Figure 3, Case 2 the electrocardiograms the heart rate was Total electrical alternans (best seen in lead Ve) below 100 per min ute; total alternans was before pericardiocentesis; the alternans is 1:1 (exact alternans); the numbers represent the present with both fast and slow heart largest part of the QRS in mm, positive or rates.
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