Assessment of LA Size and Function

Christopher Appleton, MD
Professor of Medicine
Mayo Clinic Arizona
ESE 09 Dec 2010 12:07
LA Size and Function

Left Atrium
 LA Volume – Why
y?
Helps Assess and Predict

• LV diastolic Fx – Filling Pressures

• risk new onset A-fib and CHF
• future risk of TIA / stroke

• CV morbidity - mortality
Tsang TSE et al.
LA size: Giant LA - CVA
 Mitral Flow Velocity

Normal Abnormal Abnormal Abnormal

relaxation relaxation relaxation
+ + +
Only if E wave normal / low
appropriately
LAP LAP
reduced
d d LA pressure
LV RFW LV RFW
 Diastolic Function
Classification

Normal IR IR+ PN Restrictive

Grade DHF Ia ( ? ↑LVEDP) Ib II III IV*

Inc LA size

As developed by Oh, JK * No change with Valsalva

LA size: Nl vs Pseudonormal

PN: LA Enlargement

Normal LA
 LA size: PN vs Restricted
PN: LA Enlargement
HCM-Res: Giant LA
 Abnormal LV Filling Patterns
Decrease in Compliance
Abnormal
relaxation Moderate Marked Irreversible
LV
pressure

Mitral flow
velocityy

Tissue LAE → → → →
Doppler

Pulmonary
vein

IR PN Res Irrev Res

 L ft Atrial
Left At i l Size
Si

Why Should LA Volume be

Measured ?
 LA Volume
“Observational studies, which included
6,657 patients, without a history of A-fib
or significant valvular heart disease,
disease show
that an LA volume index of ≥ 34 ml/m2 is
an independent predictor of death, heart
failure, A-fib, and ischemic stroke.”
 Prognostic
g Value of LA Size
for Predicting New Onset A-fib

Tsang TSM et al Mayo Clin Proc 2001

Left Atrial Anatomy
Insights From Cardiac CT

PV

PV

LA
LV
Cardiac CT Sagital
g thru Ao

Ao

LA

LV

Flow from LA to LV is Directed Toward

Infero-lateral Wall
Cardiac CT Sagital thru LAA

The LAA orifice has

orientation similar LAA PV
t LUL Pulm
to P l Vein
V i

LA

Mitral
Inflow
 Cardiac CT Coronal Plane

PV

PV

The LA has a
LA
complicated shape
LV
 Cardiac CT = 2
2-D
D Short Axis
2D Plax Imaging Plane

RV

PA
RA
LAA
Normal LA Length LA
Pvein – Left Upper
in 2D Plax only
Slightly > Ao
 Cardiac CT = 2 D A4C View
2-D

LV

The LA outer wall is VSD

curved; IA septum
is straight
LA

Curved
 Left Atrial Anatomy
T k H
Take Home P Points
i t
• LA has complex shape
• long axis 35 - 45o more vertical than LV*
LV
• 2-D A4C – A2C ≠ exactly 90o
• 2-D A4C – A2C views are corrected by
eye hand and not on true LV axis
eye-hand

* from Gubert F
Left Atrial Anatomy and
Physiology

Normal Function and Role

in Disease States
34 F PLAX Normal
44 F DCM PLAX
Nl LA size: 2D PShort
Bi-plane Method (A4C)
Bi-plane Method (A4C)
Bi-plane Method (A2C)
Bi-plane
p Method ((A2C))
Measuring LA Volume

Left Atrium
Bi-plane
p Method ((A4C))
 Evaluation of LA size
• MRI (gold standard)
• CT (requires validation)
• 2-D Echo methods ((all vols < MRI))
- M-mode, Prolate-ellipsoid
- Biplane Area-Length
- Biplane MM-of-Discs
of Discs (Simpson’s)
- 3D echo techniques
 Left Atrial Size
Estimating Volume

What Method to Use ?

• best accuracy
• best test – retest reproducibility
 Reference
• Lang R et al
al. 2005

"Recommendations for Chamber

Quantification: A Report
Q p from the ASE-ESE
Guidelines and Standards Committee and
the Chamber Quantification Writing Group.“
Group “

J Am Soc Echocardiog 2005;18:1440-63.

 2 D Echo Methods for
2-D
Assessment of LA Volume
n = 631 pts

Method Volume (mean ± SD) (mL)

Biplane AL 73.2 ± 26.4
Si
Simpson's
' 67 4 ± 24.8
67.4 24 8
Prolate 56 6 ± 20.4
56.6 20 4

Uji
Ujino K&T
Tsang TS ett all AJC 2006
Comparison of LA Vol Methods
n=631 pts

Distribution of
Method r= Differences, ml
(mean ± SD)
Biplane AL versus
0 98
0.98 5 7 ± 4.9
5.7 49
Simpson's
Biplane AL versus
0.85 16.5 ± 12.7
Prolate
Si
Simpson's' versus
0.86 10.8 ±13.9
Prolate

Ujino K & Tsang TS et al AJC 2006

 Calculating LA Volume
• Important
I t t!
• Although ASE-ESE recommends
both bi-plane A-L and method of
discs ….
• Method of discs has superior
p y … MOD is also
reproducibility
used for LV volumes / LVEF

Lang R et al, JASE 2005;18:1440

 LA Volume
Pearl
ea
M LA area > RA area
Max

In apical 4-chamber
4 chamber
view the maximal
(pre MVO) area of
(pre-MVO)
LA and RA is equal
 Biplane Area-Length Method

A1 = LA area, A-4C
A2 = LA area
area, A-2C
L = LA length
L
L
A1 A2

(0.85)x(A1)x(A2)
LA volume =
L
LA Volume: Area-Length Method

LA VOLUME =

8 / 3 π (A1) (A2)*
shortest L***
A-4C * A1 A2 are areas and
** L is shortest of either A4C
or A2C length
*** L1 vs L2 assumed < 1cm
**** L perpendicular Mit-ann A-2C
 LA Volume: Biplane A-L Method
L1 > L2 by 1.2 cm

A1xA2 = 224

0.85x224 = 190
190x0.37 = 70.4 ml
37 mm 70.4 ml / BSA2 =
47 mm
14 cm2

35.2 ml/m2 16 cm2

37 mm

Use longest L (47mm) Difference = 19 ml &

= 89.5 ml & 44.7 ml/m2 9.5 ml/m2
 Biplane Simpson’s Method

ai
L bi
L

π 20
LA Volume = Σ ai x bi x L
4 i=1
 Calculation of LA Volume
Summation of Disks (Simpson’s) Method

A4-Chamber A2-Chamber
LA Volume: Method of Discs (Simpson’s)
Eff t off Diff
Effect Differentt L1,
L1 L2

L1
L2

LA-L1 max 53, LA-L2 max 55 ml

Calculating
g max-min LA Volumes

LA max 55
55, LA min
i 37 ml / m2 ∆ = 32%
2-288-753-3
Appleton CP et al JACC 1993
 Bland-Altman Plots – Bi-Plane LA Volume:
Nl Subjects – ┴ to Mitral Annulus
Method of Disks
(Simpsons)y p
Area - Length
40 40
pendicular - A nterior-Poste rior (cc)

20 20

4.6 5.8
1.40 0
-1.7

-8.3

-20 -20
Perp

-40 -40
0 10 20 30 40 50 60 70 80 90 100 110 120 130 0 10 20 30 40 50 60 70 80 90 100 110 120 130
Average (cc) Average (cc)

n =80; from Vianna RP

 Bi-Plane LA Volume in Normal Subjects
Perpendicular vs Longest L from Mitral Annulus
140

Biplane Area-Length
ne (cc)
120 y = 0.98x + 6.9
r = 0.91
0 91
Mitral Plan

100 p<0.0001
Line from M

80

60 Simpson’s Method
pendicular L

y = 1.0x
1 0 + 0.9
09
40
r = 0.99
p<0.0001
Perp

20

0
0 20 40 60 80 100 120 140
Anterior-Posterior Line from Mitral Plane (cc)
n =80; from Vianna
 LA Volume
ASE - ESE Normal Values (ml / m2)
“either biplane AL or Simpson’s”

Mild Mod Severe

Normal
Increase Increase Increase

22 ± 6
29 - 33 34 - 39 > 40
ml / m2

Lang R et al, JASE 2005;18:1440

 LA VOLUME
Suggested Grading (ml / m2)

Bord Mild Mod Severe

Normal
Abn LAE LAE LAE

22 ± 6
29-33
29 33 34-39
34 39 40-46
40 46 >46
ml / m2
LA Volume Measurement: Pitfalls

• Errors of imaging planes

- foreshortening
f h t i
- failure to use “landmarks”
landmarks
• LA tracing errors – too little, too big
• A-L method: perpendicular to mitral
annulus not always longest length
LA Volume: Area Drawing
“Too Large"

A-4C A-2C
 Cardiac CT 2-D
2 D A4C

- - is longest L
vs
perpendicular
Increased LA Volume: Pitfalls
• Bradycardia = 4
4-chamber
chamber enlargement
• Inc cardiac output - anemia, fever, sepsis,
ESRD, etc… and endurance athletes
- all 4 chambers are enlarged
• Paroxysmal atrial flutter / fibrillation
• Significant
g mitral valve disease
• ↑ Body Mass Index > 35
LA enlargement
g - Bradycardia
y
Anemia Hct 16 : All 4 Chambers Enlarged
Left Atrial Volume Measurement
3-Dimensional
3 Dimensional Echo
Labor Intensive! but …
• values closest to MRI
• is inevitable with time
• greater
t accuracy absolute
b l t value
l
• >> reproducibility
-will make serial studies more
meaningful
How does 2D compare to 3D?

Khankirawatana B et al., AHJ 2004

Cardiac 3-D
3 D PLAX
 Real Time 3D A4C + 90 degrees
g

A4C A4C
+ 90
3D Apical
p 2C + 90 degrees
g
Cardiac 3-D
3 D LV to LA
Left Atrial Physiology
y gy

N
Normall Function
F ti andd Role
R l
in Disease States
70M HT – LVH – Mild LAE
LA Contractility ?
67F A4C Amyloid – LA
LA-RA
RA Failure
 Abnormal LV Filling Patterns
Decrease in Compliance
Abnormal
relaxation Moderate Marked Irreversible
LV
pressure

Mitral flow
velocityy

Tissue LAE → → → →
Doppler
PVs ↓ ↓ ↓↓
Pulmonary
vein

IR PN Res Irrev Res

 Mitral - Pulm Venous Flow Velocities
PV Systolic
S li Fraction
F i

LAE - nl PV sys fx
PVs

PVs

ith ↓ PV sys fx
LAE with f
LA Strain - Strain Rate

Vianna R and Appleton C JASE 2009

LA Strain

LA Strain
Rate

Vianna R, Appleton C JASE 2010

Thank
Th k You
Y