Pulsus bisferiens with both percussion and tidal waves occurring during systole. This type of carotid pulse contour is most frequently observed in patients with hemodynamically significant aortic regurgitation or combined aortic stenosis and regurgitation with dominant regurgitation. It is rarely appreciated at the bedside by palpation.
The bisferiens pulse, which has two systolic peaks (as shown in figure above), is characteristic of aortic regurgitation (with or without accompanying stenosis) and of hypertrophic cardiomyopathy .
In the latter condition, the pulse wave upstroke rises rapidly and forcefully, producing the first systolic peak ("percussion wave"). A brief decline in pressure follows because of the sudden midsystolic decrease in the rate of left ventricular ejection, when severe obstruction often develops.
This pressure trough is followed by a smaller and more slowly rising positive pulse wave ("tidal wave") produced by continued ventricular ejection and by reflected waves from the periphery.
