8/13/2019 electrical alternans

1/19

Electrical Alternans

- Prof.M.K.Sudhakarsunit

8/13/2019 electrical alternans

2/19

29 yr , male pt

No comorbidities

C/o cough with expectoration 1 mth

Dyspnea 15 days progressed from grade 2 to 4

No other associated complaint

O/E : Conscious, oriented, afebrile, tachypneic

PR 116/mt, BP 110/70 mmhg

CVS s1 , s2 +, no murmurs

RS NVBS +, B/L basal crepts

Abd soft , BS +

CNS - NFND

8/13/2019 electrical alternans

3/19

Labs

Hb/Plat - N

Tc 23170 (p-84.1)

RBS/RFT/Sr.Elect N

LFT T.B - 1.53 / D.B - 0.65

SGOT - 27 / SGPT 96 ESR - 62

Urine R/e N

CxR(bedside) B/L LZ congestion, cardiomegaly,B/L CP

angle blunting BNP 45.8 pg/ml

ECG NSR , no ST-T changes

Outside echo normal LV function with no RWMA

8/13/2019 electrical alternans

4/19

Pt was managed in ICU as CAP with

- O 2

- Antibiotics- other supportives

Blood, sputum & urine C/s no growth

8/13/2019 electrical alternans

5/19

On day 2

Developed hypotention ECG in ICU monitor showed

8/13/2019 electrical alternans

6/19

8/13/2019 electrical alternans

7/19

Cardiology opinion was sought from

Prof.S.Thanikachalam

Suspected to have pericardial effusion

Urgent Echo was done & found to have

massive pericardial effusion with swinging

heart

Around 750 ml pericardial fluid was drained

8/13/2019 electrical alternans

8/19

Pericardial fluid analysis

Sugar 10 mgm/dl

Protein 5.3 gm/dl

WBC 32cells/cumm(P-80%,L-20%)

RBC 7400 cells/cumm(norm-80%,cren-20%)

ADA 64 IU/L

PCR TB negative

c/s no growth

AFB not seen

Cytology mesothelial cells

8/13/2019 electrical alternans

9/19

Pt was started on ATT

Follow up echo showed very minimal

pericardial effusion

8/13/2019 electrical alternans

10/19

8/13/2019 electrical alternans

11/19

Repolarization alternans

ST segment alternans :

Alternating ST elevation - usually in presenceof MI

Causes

Acute MI

Vasospastic angina pectoris

During PTCA

Subarachnoid haemorrhage

8/13/2019 electrical alternans

12/19

8/13/2019 electrical alternans

13/19

T wave alternans : Associated with rapid changes in HR or prolonged QT

interval

Predictor of ventricular tachyarrythmias

Causes : Congenital long QT syndrome

Dyselectrolemia(hypocalcemia,hypokalemia,hypomagnesemia)

Hypertrophic cardiomyopathy

CCF

TPI

8/13/2019 electrical alternans

14/19

8/13/2019 electrical alternans

15/19

Conduction alternans

Alteration in impulse propagation along any ofanatomic structures involved in conduction of electricalimpulse

Alteration of P/QRS complex/PR interval/RR interval

Causes:

Myocardial ischaemia

AF

WPW syndrome RHD

LV dysfunction

8/13/2019 electrical alternans

16/19

8/13/2019 electrical alternans

17/19

Electrical alternans associated with

cardiac motion

Alteration in heart position in relation to

electrodes

Total electrical alternans

Causes:

Pericardial tamponade

Hypertrophic cardiomyopathyTotal electrical alternans 5 - 10 % of cardiac

tamponade cases

8/13/2019 electrical alternans

18/19

8/13/2019 electrical alternans

19/19

Thank you