Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 166-167
Authors' reply

Department of Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

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Date of Web Publication25-May-2011

How to cite this article:
Gadhinglajkar S, Sreedhar R, Jayant A. Authors' reply. Ann Card Anaesth 2011;14:166-7

How to cite this URL:
Gadhinglajkar S, Sreedhar R, Jayant A. Authors' reply. Ann Card Anaesth [serial online] 2011 [cited 2020 Oct 1];14:166-7. Available from:


We would like to thank the authors for their commentary [1] regarding our article [2] and to the Editors of Annals of Cardiac Anaesthesia for allowing us to respond to those comments.

We did not encounter any event of pulsus alternans (P ALT ) after cessation of cardiac handling despite the fact that most of the perioperative factors implicated in generation of P ALT persisted after the sternal closure. We agree with the authors that preoperative poor left ventricular ejection fraction (LVEF) could be a strong predictor for the development of P ALT during surgery and we have elaborated this point in the discussion. Underlying LV dysfunction predisposes to the alternans phenomenon after aortic valve replacement. However, the event of P ALT did not recur in the postoperative period suggests that cardiac manipulation did play a role in triggering the event after the patient was weaned from cardiopulmonary bypass (CPB). Although, we did not estimate cardiac output and systemic vascular resistance using a pulmonary artery catheter, transesophageal echocardiography (TEE) derived data shown in [Figure 3] reveals the cardiac output of 4.4 lit/ min during regular cardiac beating (presuming that average effective orifice area of a 23 mm St Jude prosthesis [3] would be 1.6 cm 2 ). Epinephrine infusion dose of 0.1 mcg/ kg/ min was optimum to provide a stable hemodynamic condition.

Hypovolemia is a known to trigger alternans phenomenon, which necessitates optimization of the intravascular volume status. However, administration of large fluid boluses may precipitate decompensation in a poorly contracting left ventricle and hence we adapted a guarded approach toward the volume infusion after termination of CPB. Left atrial pressure (LAP) during the first episode of P ALT was low. However, with frequent cardiac manipulations, elevation of the LAP later in the post-CPB period did not prevent further episodes of alternans. Similar fluctuations in the preload did not stimulate the P ALT in the postoperative period after sternal closure. Although, vasodilators may be beneficial in offloading the LV, they may induce P ALT in patients with cardiac dysfunction. [4]

Published human studies have demonstrated that P ALT may be induced using rapid atrial pacing in the presence of deranged cardiac function. In these patients, P ALT was not noticed when the heart rate was at its baseline value. Pacing at a higher rate or converting the rhythm to supraventricular tachycardia was required to trigger the phenomenon in most of them. [5],[6],[7] Atrium was paced at a rate of 90/ minute in our patient, which was near baseline value prior to the surgery and was unlikely to induce P ALT . Authors suggest that rapid atrial pacing-evoked alternans could be abolished by intravenous infusion of epinephrine. Alternans occurred frequently in our patient despite administration of epinephrine infusion is another reason to believe that it was not triggered by the atrial pacing.

In summary, although an undesirable sequel, the P ALT is difficult to prevent, when heart is handled in the post-CPB period after aortic valve replacement in patients with severe cardiac dysfunction.

   References Top

1.Jain A. Pulsus alternans after aortic valve replacement: A preventable yet a possible risk of cardiac manipulation: Fact or fiction? Ann Card Anaesth 2011;14:165-6.  Back to cited text no. 1
  Medknow Journal  
2.Gadhinglajkar S, Sreedhar R, Jayant A. Pulsus alternans after aortic valve replacement: Intraoperative recognition and role of TEE. Ann Card Anaesth 2010;13:181-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Rosenhek R, Binder T, Maurer G, Baumgartner H. Normal values for Doppler echocardiographic assessment of heart valve prostheses. J Am Soc Echocardiogr 2003;16:1116-27.  Back to cited text no. 3
4.Matsuhashi H, Onodera S, Hasebe N, Maruyama J, Honda H, Yamashita H, et al. Transient pulsus alternans induced by isosorbide dinitrate: Echocardiographic and hemodynamic evidence of reduced venous return: A case report. Angiology 1991;42:504-11.  Back to cited text no. 4
5.Hirashiki A, Izawa H, Somura F, Obata K, Kato T, Nishizawa T, et al. Prognostic value of pacing-induced mechanical alternans in patients with mild-to-moderate idiopathic dilated cardiomyopathy in sinus rhythm. J Am Coll Cardiol 2006;47:1382-9.  Back to cited text no. 5
6.Goldreyer BN, Kastor JA, Kershbaum KL. The hemodynamic effects of induced supraventricular tachycardia in man. Circulation 1976;54:783-9.  Back to cited text no. 6
7.Schaefer S, Malloy CR, Schmitz JM, Dehmer GJ. Clinical and hemodynamic characteristics of patients with inducible pulsus alternans. Am Heart J 1988;115:1251-7.  Back to cited text no. 7

Correspondence Address:
Shrinivas Gadhinglajkar
Department of Anaesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala-695 011
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Source of Support: None, Conflict of Interest: None

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