In the image above, the pulsus bisferiens (panel A) developed acutely on the first postoperative day in a patient on peripherally placed extracorporeal membrane oxygenation (ECMO). ECMO was started intraoperatively because of the inability to separate from cardiopulmonary bypass because of profound vasoplegia after aortic valve replacement. Pulsus bisferiens is a feature of severe aortic regurgitation. It shows two upstrokes of arterial pressure trace during systole and wide pulse pressure may concomitantly be present.1 A similar waveform may also be visible in hypertrophic obstructive cardiomyopathy, severe mitral valve prolapse, and sepsis. In our patient, severe aortic regurgitation was confirmed with transesophageal echocardiogram (panel B) that showed holodiastolic retrograde flow in the descending thoracic aorta and aortic regurgitation with Doppler (panel C). It is essential to promptly diagnose acute aortic regurgitation in patients on peripheral venoarterial ECMO to avoid sudden volume overloading of the left ventricle from aortic regurgitation.2 Management includes avoiding vasopressors to increase afterload but instead using inotropes to maintain chronotropy and inotropy to favor forward flow. Temporizing measures to avoid severe ventricular overloading include left atrial septostomy, left ventricular venting, and placement of an Impella device. However, emergent surgical repair of the aortic valve is prudent.3 In our patient, we decreased ECMO flow and weaned off vasopressin while concomitantly increasing epinephrine as we made arrangements for the surgical intervention. Timely and successful surgical intervention on the aortic valve resulted in an excellent outcome.
Competing Interests
The authors declare no competing interests.
