Bisferiens peaks in the radial artery pressure wave during patent ductus arteriosus in newborn infants: relationship with ascending aortic flow

Previously, we found evidence that bisferiens peaks in the radial artery pressure wave in the newborn infant may suggest the presence of a left-to-right shunt through a patent ductus arteriosus (PDA). The purpose of the present study was to analyze the origin of this pulsus bisferiens. Starting from the assumption that the radial artery pressure wave form is similar to the aortic pressure wave form, as described previously, we attempted to explain the bisferiens peaks on the basis of echocardiographically obtained ascending aortic flow. We studied 11 preterm mechanically ventilated infants with a left-to-right shunt through a PDA and 7 without. Aortic volume flow was established echocardiographically, and radial artery blood pressure measurement was performed with a high fidelity cathetermanometer system. Ascending aortic peak flow during PDA was significantly higher in the case of PDA, compared with the case without PDA. An augmented peak flow with an abrupt decline after the high peak in PDA, resulting in a sharp pressure peak with a steep decline after the peak, was thought to explain the first sharp peak of pulsus bisferiens. An abrupt decline of flow after peak flow is thought to be due to the fast runoff of blood through the ductus. According to the pulsatile pressure dynamics theories, which state that pressure wave forms consist of forward and backward wave forms, the second peak of the pulsus bisferiens can be explained by the return of the reflected (backward) wave form when the forward wave form has already considerably decreased. We conclude that the bisferiens peaks found in PDA result from a combination of large stroke volume (augmented first peak) and large runoff (quick decline of the forward wave) before the return of the reflected wave.