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Electrical alternans and its resolution in an adult with a large pericardial effusion

A 33-year-old man with a history of metastatic chondrosarcoma presented to the emergency room one day after a syncopal episode. He was afebrile with heart rate of 104 beats/min; blood pressure 95/68 mmHg with 15 mmHg of pulsus paradoxus. He had jugular venous distension, clear lung fields, and distant heart sounds without murmurs or rub. Electrocardiogram (ECG) demonstrated electrical alternans (Fig. 1A) and echocardiography showed a large pericardial effusion with right ventricular and right atrial compression (Fig. 2). Pericardiocentesis removed 1,600 cc of serosanguineous fluid with resolution of clinical and hemodynamic evidence of tamponade. Post-pericardiocentesis ECG demonstrated resolution of electrical alternans (Fig. 1B). Reference Spodick D: Acute cardiac tamponade. N Engl J Med 2003;349(7): 684–690 Images edited by Richard A. Kerensky, M.D.