1. Systolic and Diastolic Pulsus Alternans in Severe Heart Failure
Gila Perk, MD, Paul A. Tunick, MD, Itzhak Kronzon, MD, FASE 
Journal of the American Society of Echocardiography 
Volume 20, Issue 7, Pages 905.e5-905.e7 (July 2007)
DOI: /j.echo
Copyright © 2007 American Society of Echocardiography Terms and Conditions

2. Figure 1
Continuous wave Doppler of transaortic flow velocity. Peak velocity of transaortic flow shows significant beat-to-beat variation, alternating between 0.8 and 0.4 m/s. This correlates with physical finding of alternating systolic blood pressure–pulsus alternans.
Journal of the American Society of Echocardiography  , 905.e5-905.e7DOI: ( /j.echo )
Copyright © 2007 American Society of Echocardiography Terms and Conditions

3. Figure 2
Continuous wave Doppler of transmitral flow velocity. Marked beat-to-beat alternation in diastolic mitral inflow pattern is noted. Despite being in sinus rhythm, E and A wave of mitral inflow velocity are fused because of patient’s significant tachycardia. Peak velocity alternates between 1.2 and 0.8 m/s. This represents diastolic alternans possibly resulting in alternating loading conditions. Also noted, alternating dP/dt on mitral regurgitation (MR) tracing, with higher dP/dt in beat following the higher E velocity, and lower dP/dt following the beats with lower E.
Journal of the American Society of Echocardiography  , 905.e5-905.e7DOI: ( /j.echo )
Copyright © 2007 American Society of Echocardiography Terms and Conditions

4. Figure 3
Pulsed wave tissue Doppler at lateral mitral annulus. Significant beat-to-beat variation in both systolic and diastolic tissue velocities is noted. Peak systolic velocity alternates between 3 and 2 cm/min. Peak early diastolic velocity alternates between 8 and 6 cm/s.
Journal of the American Society of Echocardiography  , 905.e5-905.e7DOI: ( /j.echo )
Copyright © 2007 American Society of Echocardiography Terms and Conditions