Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital,Old Rajinder Nagar, New Delhi - 110 060
India

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Sir,

A 48-years-male patient presented with acute anterior wall myocardial infarction with cardiogenic shock. Transthoracic echocardiography revealed large post MI ventricular septal rupture. Intra-aortic balloon pump (IABP) was inserted and patient was scheduled for emergency coronary artery bypass grafting surgery and ventricular septal repair under cardiopulmonary bypass (CPB). During weaning from bypass, IABP was restarted to decrease the afterload and increase cardiac output. Arterial waveform showed four peaks [Figure 1]. Normal arterial wave is having only one peak. In patient with IABP, four peaks (systolic and augmented diastolic peak) are observed. Post bypass peripheral vasoconstriction may be responsible for early backward progression of reflected wave creating four peaks in waveform. Such abnormal waveform implies increased afterload on heart which is not favorable in weaning patient from CPB. Pulmonary artery catheter was inserted. Hemodynamic variables obtained also showed raised systemic vascular resistance. Milrinone intravenous infusion was started to reduce afterload. Arterial waveform gradually returned back to normal two peak waveform of IABP.{Figure 1}