Biventricular pulsus alternans

Pulsus alternans is alternating volume of pulse, with a regular rhythm, mostly seen with severe left ventricular dysfunction. Biventricular and right ventricular pulsus alternans needs cardiac catheterization or Doppler echocardiography to demonstrate the alternating right ventricular or pulmonary artery systolic pressures. Biventricular pulsus alternans is much rarer than left ventricular pulsus alternans. One case reported was biventricular pulsus alternans due to anterior wall myocardial infarction [1]. Another report was an echocardiographic demonstration of biventricular pulsus alternans by echocardiography in a case of pulmonary embolism [2]. A combination of dilated cardiomyopathy and pulmonary embolism was responsible for biventricular pulsus alternans in another case [3]. The demonstration of alternans was the alternating left ventricular and right ventricular outflow velocities. A diastolic alternans was also described in the inflow velocities, though strictly the term diastolic pulsus alternans is not ideal because there is no pulse in diastole in this case!


  1. Vidwan P, Stouffer GA. Biventricular pulsus alternans. Cardiol Res Pract. 2009;2009:703793.
  2. Nguyen T, Cao LB, Tran M, Movahed A. Biventricular pulsus alternans: An echocardiographic finding in patient with pulmonary embolism. World J Clin Cases. 2013 Aug 16;1(5):162-5.
  3. Szymanski P, Lipczynska M, Klisiewicz A, Hoffman P. “Like a sound and its echo”. Biventricular pulsus alternans. Heart. 2014 Jan;100(1):83, 90.