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In the image above, the pulsus bisferiens (panel A) developed acutely on the first postoperative day in a patient on peripherally placed extracorporeal membrane oxygenation (ECMO). ECMO was started intraoperatively because of the inability to separate from cardiopulmonary bypass because of profound vasoplegia after aortic valve replacement. Pulsus bisferiens is a feature of severe aortic regurgitation. It shows two upstrokes of arterial pressure trace during systole and wide pulse pressure may concomitantly be present. 1 A similar waveform may also be visible in hypertrophic obstructive cardiomyopathy, severe mitral valve prolapse, and sepsis. In our patient, severe aortic regurgitation was confirmed with transesophageal echocardiogram (panel B) that showed holodiastolic retrograde flow in the descending thoracic aorta and aortic regurgitation with Doppler (panel C). It is essential to promptly diagnose acute …