Mechanical cardiac alternans is usually associated with left ventricular
dysfunction. Atrial alternans has been described on invasive assessment
of atrial action potentials, however cannot be detected clinically.
Herein we report a patient who had transthyretin type cardiac
amyloidosis with prior history of recurrent atrial fibrillation
requiring ablations as well as ablation for atrial flutter and a recent
history of cardioversion for atrial flutter. The patient presented with
diastolic heart failure and recurrent atrial flutter and was referred
for a TEE guided cardioversion. Mechanical left and right atrial
alternans was seen on Doppler interrogation of both atrial appendages
with velocities corresponding to the flutter P wave on the ultrasound
ECG monitor. The patient was successfully cardioverted with the TEE
probe in situ. Post cardioversion TEE showed resumption of normal albeit
reduced mechanical atrial function in the left atrium and preserved
right atrial function in tissue Doppler imaging. Our case demonstrates
the mechanical phenomenon of atrial alternans in both atria on TEE with
disappearance of atrial alternans during sinus rhythm suggesting rate
related atrial alternans likely related to atrial stiffness from amyloid
infiltration and as well as possibly scar formation from prior
ablations.