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(Circulation. 2006;113:e866-e868.)
© 2006 American Heart Association, Inc.

Images in Cardiovascular Medicine

Echocardiographic Demonstration of Electrical Alternans

Sreedhar Billakanty, MD; Riyaz Bashir, MD

From the Medical University of Ohio, Toledo.

Correspondence to Riyaz Bashir, MD, Division of Cardiovascular Medicine, Medical University of Ohio, 300 Arlington Ave, Toledo, OH 43614. E-mail rbashir{at}mco.edu

A 49-year-old male with a history of small-cell lung cancer and distant metastasis presented with progressive dyspnea on exertion lasting 2 weeks. Physical examination demonstrated a pulse of 118 beats per minute, blood pressure of 104/62 mm Hg, jugular venous pressure of 15 cm water, pulsus paradoxus of 20 mm Hg, clear lungs, and distant heart sounds. The 12-lead ECG revealed sinus tachycardia and electrical alternans (Figure 1). Echocardiography (Figure 2A and 2B and Movie) showed a beat-to-beat swinging motion with a nearly 90° change in position of the heart in large pericardial effusion. This beat-to-beat mechanical swinging motion of heart from position A (QRS A) to position B (QRS B) explains the shift in QRS axis and hence the "electrical alternans" seen on surface ECG. Pericardiocentesis to remove 1000 mL of bloody fluid resulted in prompt clinical improvement and disappearance of the electrical alternans (Figure 3). Subsequently, the patient underwent pericardial "window."

View larger version (53K): [in this window] [in a new window]   Figure 1. Twelve-lead ECG shows electrical alternans (QRS A and QRS B).

View larger version (66K): [in this window] [in a new window]   Figure 2. Two-dimensional echocardiographic images show large pericardial effusion and electrical alternans. The apical 4-chamber view shows swinging motion of the heart, with beat-to-beat change in the orientation of the ventricle resulting in alternating QRS vectors (QRS A and QRS B) on the ECG. Also see the online-only Movie.

View larger version (77K): [in this window] [in a new window]   Figure 3. Twelve-lead ECG after pericardiocentesis. The electrical alternans is no longer seen.

	Acknowledgments

 
Disclosures

None.

	Footnotes

 
The Movie is available in the online-only Data Supplement at http://circ.ahajournals.org/cgi/content/full/113/24/e866/DC1.

This Article Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Billakanty, S. Articles by Bashir, R. Search for Related Content PubMed Articles by Billakanty, S. Articles by Bashir, R. Related Collections Electrocardiology Pericardial disease Echocardiography