FIRST HEART SOUND ALTERNANS IN MASSIVE PERICARDIAL EFFUSION

First heart sound alternans in the absence of pulsus alternans, or variation in heart rate (i.e., variation in PR interval), occurring in a patient with massive neoplastic pericardial effusion is described. The mechanism appears to be similar to that in electrical alternans and is shown by echocardiography to be related to the cardiac position within the pericardium, with the first heart sound intensity varying according to the distance of the heart from the chest wall. First heart sound alternans, electrical alternans, and alternating cardiac motion within the pericardium disappeared following pericardiocentesis.