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case_images: Haemodynamic parameters before and after ivabradine. On the transfer day, the heart rate was 135/min, and arterial pressure waves of the left ventricular ejection showed pulsus alternans (A, white arrows; s, strong beat; W, weak beat). The subsequent diastolic augmentation waves by IABP also showed pulsus alternans (A, white circles). Brief cessation of IABP made pulsus alternans clearer (B, white arrows), despite the prominent dicrotic notches and reflection waves. Note that the amplitude of the pulsus alternans, or the difference between strong and weak beats, stayed at ~10 mmHg, regardless of on IABP or off IABP. Ivabradine 2.5 mg twice daily reduced his heart rate to 95/min within 2 days. The arterial waves showed that pulsus alternans disappeared under IABP support (C, white arrows) and was not caused by a brief cessation of IABP (D, white arrows). Respiratory fluctuations of AP were parallel to PAWP. AP, arterial pressure; PAWP, pulmonary artery wedge pressure; RAP, right atrial pressure.
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case_images: PAP, 40/25(31) mmHg; mRAP, 10 mmHg; SvO2, 55.4%; and CI, 2.18 L/min/m2. Arterial pressure waves indicated pulsus alternans (Figure 1A and B, white arrows). Precordial pulsations and a shift of the apex to the left were apparent. Furthermore, arterial waveforms revealed the disappearance of pulsus alternans (Figure 1C and D).
case_images: Chest radiograph and electrocardiogram at the transfer to our hospital.
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case_images: Chest radiography and electrocardiogram detected marked cardiomegaly, sinus tachycardia, and mild ST-T abnormalities without T-wave alternans (Figure 2A and B).
case_images: Clinical course. CI, cardiac index; HR, heart rate; l-AP, lower arterial pressure; PAWP, pulmonary artery wedge pressure; RAP, right atrial pressure; SvO2, O2 saturation of mixed vein; U-AP, upper arterial pressure.
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case_images: Two days later, his HR decreased to ~100/min, without decreasing SvO2 or CI, and PAWP decreased without change in diuretics (Figure 3), as follows: HR, 107/min; AP, 98/59(78) mmHg; mPAWP, 17 mmHg; PAP, 40/22(29) mmHg; mRAP, 9 mmHg; SvO2, 65.3%; and CI, 2.84 L/min/m2.
case_images: Endomyocardial biopsy examination. Myocardial hypertrophy and vacuolization of left ventricular tissue 31 days after the transfer (A, B) and milder myocardial hypertrophy and vacuolization of right ventricular tissue on Day 55 (C, D) were observed with Masson's trichrome staining.
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case_images: Endomyocardial biopsy of the right ventricle on Day 55 showed milder myocardial enlargement and vacuolation (Figure 4C and D) compared to the biopsy done on the left ventricle at the previous hospital 31 days before transfer (Figure 4A and B).