Total electrical alternans in a patient with malignant pericardial tamponade

Abstract

We present a case of a 59-year-old man with acute abdominal pain and progressive shortness of breath. A focused assessment with sonography for trauma scan showed free fluid in the hepatorenal recess and in the recto-uterine recess. Later, due to clinical deterioration and the differential possibility of a pulmonary embolism or aortic dissection, a CT scan was performed which revealed large pericardial effusion. This, together with a dilated vena cava inferior and portal system, raised the suspicion of cardiac tamponade. The diagnosis was confirmed by transthoracic echocardiography (TTE). In retrospect, the ECG at admission showed a sinus tachycardia, low-voltage QRS complexes and a total electrical alternans corresponding with the swinging heart seen on TTE. An electrical alternans on ECG is an important diagnostic clue but is often missed, causing an unnecessary delay to proper diagnostic and therapeutic measures.

ECG Changes Post-pericardiocentesis for Cardiac Tamponade Secondary to Non-small Cell Carcinoma of the Lung

“…The sign is defined as an alternating height of electrical complexes arising from the same pacemaking site. Any ECG wave can show this change, but it is most often observed with the QRS complex [1]. A mechanism that contributes to this finding is the pendular motion of the heart throughout the cardiac cycle from accumulated pericardial fluid [4].…”

“…It is common for patients to present in distress and they often complain of chest pain and dyspnea. Physical exam findings reflect the decreased filling capacity of the heart chambers, leading to tachycardia, hypotension, jugular venous distension, and pulsus paradoxus [1]. Findings on electrocardiograph (ECG) may include electrical alternans, low QRS voltage, P wave, and T wave changes [2].…”

Would the Addition of Immunotherapy Impact the Prognosis of Patients With Malignant Pericardial Effusion?

“…Radiological assessment for MPE includes a chest X-ray (CXR) that would show an enlarged cardiac silhouette with clear lungs. The "water bottle sign" is the classic sign of pericardial effusion (8) pericardial effusion (7,9). Although 12-lead ECG findings of low voltage and electrical alternans suggest pericardial effusion, they are poorly diagnostic and nonspecific for pericardial effusion and cardiac tamponade (10,11).…”