Murmur alternans in aortic stenosis.

Acquired aortic stenosis, when severe, often gives rise to pulsus alternans.' Other relatively common causes for pulsus alternans include hypertensive heart disease, coronary artery disease, syphilitic heart disease and cardi~myopathy.~ When pulsus alternans is present, the clinician can usually appreciate it through the use of a sphygmomanometer, in which case when the cuff is infiated to near systolic levels, Korotkoff sounds are transmitted below the cuff with alternate beats. Alternating strength of cardiac contraction may sometimes be ascertained by cardiac auscultation: the first heart sound, the second heart sound and ejection sounds have all been observed to be greater in amplitude with stronger beats.3 Fort et a14 have reported a case with idiopathic cardiomyopathy manifesting pulsus alternans in whom a summation gallop sound was seen to alternate with each alternating beat. Occasional reference6v6 has been made to alternating systolic murmurs in certain cases with pulsus alternans. We wish to report, herein, the case of aortic stenosis with not only striking alternation of a systolic murmur, but also with an alternating diastolic gallop, first and second heart sounds. GRAPHIC TECHNIQUES IN CARDIOLOGY