Use of Real-time Three-dimensional Echocardiography to Measure Left Atrial Volume: Comparison with Other Echocardiographic Techniques

Unified adult transthoracic echocardiographic report: an expert consensus document of the Egyptian Working Group of Echocardiography

BACKGROUND

Physicians face complexity in interpreting the results of echocardiography (ECHO) due to the variability across ECHO laboratories. Many international organizations published reports to reduce the inter-variability in ECHO reporting. However, with the evolution of imaging modalities, significant improvements in ECHO reporting are essential to eliminate any previous discrepancies. The Egyptian Working Group of Echocardiography (EEWG) aimed to prepare a standardized, updated, simple, and comprehensive ECHO reporting in Egypt to offer consistency, guarantee that all the crucial features are fulfilled, and ease practitioners' communication to maximize clinical decision-making.

MAIN TEXT

Relevant articles were retrieved and reviewed to explore the current state of TTE reporting practices, existing guidelines, and challenges faced by physicians in interpreting TTE results. Identified gaps and areas for improvement were then employed to establish the outline for the standardization approach. This report addresses crucial components such as demographic data, measurements, and interpretative summaries. It emphasizes left ventricle measurements and systolic function assessment, incorporating advanced techniques like speckle tracking and three-dimensional imaging. The significance of evaluating diastolic function, examining the right ventricle, and assessing valves, pericardium, and aorta are also discussed.

CONCLUSION

The current consensus goals to streamline communication among practitioners contribute to a more unified approach to interpreting ECHO results. Our initiative marks a significant step forward in enhancing the standardization and quality of ECHO reporting in Egypt. By introducing this report and encouraging continuous learning, the working group aims to raise the overall reporting quality and facilitate interpretation across diverse echocardiographic settings. This concerted effort improves patient care by ensuring consistency, accuracy, and relevance in interpreting echocardiographic findings.

Atrial Fibrillation, Atrial Myopathy, and Thromboembolism: The Additive Value of Echocardiography and Possible New Horizons for Risk Stratification

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient's stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The "ABC" pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients' management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.

Normal values for left atrial strain, volume, and function derived from 3D echocardiography: the Copenhagen City Heart Study

AIMS

3D echocardiographic (3DE) assessment of the left atrium (LA) is a new modality of potential clinical value. Age- and sex-based normative values are needed to benchmark these parameters for clinical use.

METHODS AND RESULTS

Of 4466 participants in the 5th Copenhagen City Heart Study, a prospective longitudinal cohort study on the general population, 2082 participants underwent 3DE of the LA. Healthy participants were included to establish normative values for LA strain, volume, and function by 3DE. The effects of age and sex were also evaluated. After excluding participants with comorbidities, 979 healthy participants (median age 44 years, 39.6% males) remained. The median and limits of normality (2.5th and 97.5th percentiles) for functional and volumetric measures were as follows: LA reservoir strain (LASr) 30.8% (18.4-44.2%), LA conduit strain (LAScd) 19.1% (6.8-32.0%), LA contractile strain 11.7% (4.3-22.2%), total LA emptying fraction (LAEF) 61.4% (47.8-71.0%), passive LAEF 37.7% (17.4-53.9%), active LAEF 37.4% (22.2-52.5%), LA minimum volume index (LAVimin) 10.2 (5.9-18.5) mL/m2, and LA maximum volume index (LAVimax) 26.8 (16.5-40.1) mL/m2. All parameters changed significantly with increasing age (P value for all <0.001). Significant sex-specific differences were observed for all parameters except active LAEF and LAVimax. Sex significantly modified the association between age and LASr (P for interaction < 0.001), LAScd (P for interaction < 0.001), LAVimin (P for interaction = 0.037), and total LAEF (P for interaction = 0.034) such that these parameters deteriorated faster with age in females than males.

CONCLUSION

We present age- and sex-specific reference material including limits of normality for LA strain, volume, and function by 3DE.

Validation of Left Atrial Volume Correction for Single Plane Method on Four-Chamber Cine Cardiac MRI

BACKGROUND

Left atrial (LA) assessment is an important marker of adverse cardiovascular outcomes. Cardiovascular magnetic resonance (CMR) accurately quantifies LA volume and function based on biplane long-axis imaging. We aimed to validate single-plane-derived LA indices against the biplane method to simplify the post-processing of cine CMR.

METHODS

In this study, 100 patients from Leeds Teaching Hospitals were used as the derivation cohort. Bias correction for the single plane method was applied and subsequently validated in 79 subjects.

RESULTS

There were significant differences between the biplane and single plane mean LA maximum and minimum volumes and LA ejection fraction (EF) (all p < 0.01). After correcting for biases in the validation cohort, significant correlations in all LA indices were observed (0.89 to 0.98). The area under the curve (AUC) for the single plane to predict biplane cutoffs of LA maximum volume ≥ 112 mL was 0.97, LA minimum volume ≥ 44 mL was 0.99, LA stroke volume (SV) ≤ 21 mL was 1, and LA EF ≤ 46% was 1, (all p < 0.001).

CONCLUSIONS

LA volumetric and functional assessment by the single plane method has a systematic bias compared to the biplane method. After bias correction, single plane LA volume and function are comparable to the biplane method.

Cardiac Imaging for the Assessment of Left Atrial Mechanics Across Heart Failure Stages

The left atrium (LA) is emerging as a key element in the pathophysiology of several cardiac diseases due to having an active role in contrasting heart failure (HF) progression. Its morphological and functional remodeling occurs progressively according to pressure or volume overload generated by the underlying disease, and its ability of adaptation contributes to avoid pulmonary circulation congestion and to postpone HF symptoms. Moreover, early signs of LA dysfunction can anticipate and predict the clinical course of HF diseases before the symptom onset which, particularly, also applies to patients with increased risk of HF with still normal cardiac structure (stage A HF). The study of LA mechanics (chamber morphology and function) is moving from a research interest to a clinical application thanks to a great clinical, prognostic, and pathophysiological significance. This process is promoted by the technological progress of cardiac imaging which increases the availability of easy-to-use tools for clinicians and HF specialists. Two-dimensional (2D) speckle tracking echocardiography and feature tracking cardiac magnetic resonance are becoming essential for daily practice. In this context, a deep understanding of LA mechanics, its prognostic significance, and the available approaches are essential to improve clinical practice. The present review will focus on LA mechanics, discussing atrial physiology and pathophysiology of main cardiac diseases across the HF stages with specific attention to the prognostic significance. Imaging techniques for LA mechanics assessment will be discussed with an overlook on the dynamic (under stress) evaluation of the chamber.

Correlation between Volumes Determined by Echocardiography and Cardiac MRI in Controls and Atrial Fibrillation Patients

Aims: We aimed to compare cardiac volumes measured with echocardiography (echo) and cardiac magnetic resonance imaging (MRI) in a mixed cohort of healthy controls (controls) and patients with atrial fibrillation (AF). Materials and methods: In total, 123 subjects were included in our study; 99 full datasets were analyzed. All the participants underwent clinical evaluation, EKG, echo, and cardiac MRI acquisition. Participants with full clinical data were grouped into 63 AF patients and 36 controls for calculation of left atrial volume (LA Vol) and 51 AF patients and 30 controls for calculation of left ventricular end-diastolic volume (LV EDV), end-systolic volume (ESV), and LV ejection fraction (LV EF). Results: No significant differences in LA Vol were observed (p > 0.05) when measured by either echo or MRI. However, echo provided significantly lower values for left ventricular volume (p < 0.0001). The echo LA Vol of all the subjects correlated well with that measured by MRI (Spearmen correlation coefficient r = 0.83, p < 0.0001). When comparing the two methods, significant positive correlations of EDV (all subjects: r = 0.55; Controls: r = 0.71; and AF patients: r = 0.51) and ESV (all subjects: r = 0.62; Controls: r = 0.47; and AF patients: r = 0.66) were found, with a negative bias for values determined using echo. For a subgroup of participants with ventricular volumes smaller than 49.50 mL, this bias was missing, thus in this case echocardiography could be used as an alternative for MRI. Conclusion: Good correlation and reduced bias were observed for LA Vol and EF determined by echo as compared to cardiac MRI in a mixed cohort of patients with AF and healthy volunteers. For the determination of volume values below 49.50 mL, an excellent correlation was observed between values obtained using echo and MRI, with comparatively reduced bias for the volumes determined by echo. Therefore, in certain cases, echocardiography could be used as a less expensive, less time-consuming, and contraindication free alternative to MRI for cardiac volume determination.

Imaging of the left atrium: pathophysiology insights and clinical utility

Left atrial imaging and detailed knowledge of its pathophysiology, especially in the context of heart failure, have become an increasingly important clinical and research focus. This development has been accelerated by the growth of non-invasive imaging modalities, advanced image processing techniques, such as strain imaging, and the parallel emergence of catheter-based left atrial interventions like pulmonary vein ablation, left atrial appendage occlusion, and others. In this review, we focus on novel imaging methods for the left atrium, their pathophysiological background, and their clinical relevance for various cardiac conditions and diseases.

Variability of echocardiographic measures of left ventricular diastolic function. The HUNT study

OBJECTIVE

Investigate variability related to image acquisition and reading process for echocardiographic measures of left ventricular (LV) diastolic function, and its influence on classification of LV diastolic dysfunction (LVDD).

METHODS

Forty participants (19 women) mean age 62 (28-88) years underwent echocardiographic examinations twice by different echocardiographers and blinded analyses by four readers in a cross-sectional design. Measurements included quantification of two- (2D) and three-dimensional (3D) recordings of the left atrium (LA) (maximal) volume (LAV_max ) and spectral Doppler blood flow and tissue velocities for assessment of LV diastolic function. Variability and reproducibility measures were calculated using variance component analyses and Kappa statistics.

RESULTS

Image acquisition influenced variability more than image reading (mean 24% and 4% of variance, respectively), but variability from image reading was especially important for 2D LAV_max (16% of variance) compared to 4% for 3D LAV_max , which was reflected in better agreement for 3D measures. The variability of measures used in classification of LVDD had clinical significance, and agreement across the four raters in classification using current recommendations was only fair (Kappa 0.42), but the agreement improved when using 3D LAV_max (Kappa 0.58). Agreement and reliability measures were reported for all measures.

CONCLUSION

Performing a new image acquisition influenced variability more than a introducing a new image reader, but there were differences across the different measures. LAV_max by 3D is superior to 2D with respect to lower variability. The variability of diastolic measures influences the reliability of LVDD classification, and this should be taken into account in the everyday clinic.

Assessment of biatrial function in clinically well pediatric bicaval heart transplantation patients by three-dimensional echocardiography

Atrial size and function are closely correlated with atrial contributions to cardiovascular performance. Therefore, in this study, we aimed to assess atrial size and function in pediatric heart transplantation (HTx) patients using three-dimensional echocardiography (3DE). We enrolled 33 clinically well pediatric HTx patients and 33 healthy controls with a similar distribution of sex and age to the HTx patients. All patients underwent two-dimensional echocardiography (2DE) and 3DE. 2DE- and 3DE-derived biatrial maximal volume (Vmax), minimal volume (Vmin), ejection volume (EV), ejection fraction (EF), volume before atrial contraciton (VpreA), passive EV, passive EF, active EV and active EF were obtained in all patients. The 3D left atrail (LA) Vmax, Vmin and VpreA increased significantly in HTx patients after being indexed by BSA, while 3D LAEV and passive EV decreased significantly (P < 0.05). Moreover, the 3D LAEF, LA passive EF, and LA active EF all decreased significantly in HTx patients (P < 0.05). The 3D right atrial (RA) Vmax, Vmin, and VpreA increased significantly in HTx patients (P < 0.05), while the 3D RAEF and RA passive EF decreased significantly in HTx patients (P < 0.05). 3DE-derived LAVmax, LAVpreA, LA passive EV, LAEF, and LA passive EF were all lower than the corresponding 2D parameters. 3DE-derived RAVpreA, RA passive EV and RAEF were all lower than the corresponding 2D parameters. Atrial sizes and function assessed by 3DE- and 2DE-derived parameters, yield significantly discordant results in pediatric HTx patients. 3DE confirms significantly enlarged atrial sizes and decreased atrial functions in pediatric HTx patients.

Assessment of left ventricular diastolic function by three-dimensional transthoracic echocardiography

Doppler echocardiography assessment of left ventricular (LV) filling pressures at rest and during exercise is the most widely used imaging technique to assess LV diastolic function in clinical practice. However, a sizable number of patients evaluated for suspected LV diastolic function show an inconsistency between the various parameters included in the flowchart recommended by current Doppler echocardiography guidelines and results in an undetermined LV diastolic function. Current three-dimensional echocardiography technology allows obtaining accurate measurements of the left atrial volumes and functions that have been shown to improve the diagnostic accuracy and prognostic value of the algorithms recommended for assessing both LV diastolic dysfunction and heart failure with preserved ejection fraction. Moreover, current software packages used to quantify LV size and function provide also volume-time curves showing the dynamic LV volume change throughout the cardiac cycle. Examining the diastolic part of these curves allows the measurement of several indices of LV filling that have been reported to be useful to differentiate patients with normal LV diastolic function from patients with different degrees of diastolic dysfunction. Finally, several software packages allow to obtain also myocardial deformation parameters from the three-dimensional datasets of both the left atrium and the LV providing additional functional parameters that may be useful to improve the diagnostic yield of three-dimensional echocardiography for the LV diastolic dysfunction. This review summarizes the current applications of three-dimensional echocardiography to assess LV diastolic function.

Image Guided Mitral Valve Replacement: Registration of 3D Ultrasound and 2D X-ray Images

Mitral valve repair or replacement is important in the treatment of mitral regurgitation. For valve replacement, a transcatheter approach had the possibility of decrease the invasiveness of the procedure while retaining the benefit of replacement over repair. However, fluoroscopy images acquired during the procedure provide no anatomical information regarding the placement of the probe tip once the catheter has entered a cardiac chamber. By using 3D ultrasound and registering the 3D ultrasound images to the fluoroscopy images, a physician can gain a greater understanding of the mitral valve region during transcatheter mitral valve replacement surgery. In this work, we present a graphical user interface which allows the registration of two co-planar X-ray images with 3D ultrasound during mitral valve replacement surgery.

Performance of a new fully automated transthoracic three-dimensional echocardiographic software for quantification of left cardiac chamber size and function: Comparison with 3 Tesla cardiac magnetic resonance

PURPOSE

To evaluate the accuracy and reproducibility of a new fully automated fast three-dimensional (3D) transthoracic echocardiography (TTE) software for the simultaneous assessment of left atrial (LA) volumes and LA ejection fraction (EF), left ventricular (LV) volumes, LV mass, and LVEF, and to compare the results obtained with a cardiac magnetic resonance (CMR) reference.

METHODS

We included retrospectively 56 patients (46 men; mean age 63 ± 13 years) in sinus rhythm who had had comprehensive 3D TTE and CMR examinations within 24 hours.

RESULTS

Despite a slight underestimation of LV and LA volumes, LVEF and LAEF were similar using CMR or 3DTTE (58% ± 16% vs 58% ± 12%; P = .65 and 45% ± 14% vs 46% ± 15%; P = .38, respectively) in the total population. Despite significant correlation between TTE and CMR measurements (r = 0.78; P < .001), 3D TTE underestimated LV mass (bias = -27 ± 35 g).

CONCLUSION

3D TTE using a new-generation fully automated software is a fast and reproducible imaging modality for simultaneous extensive quantification of left heart chambers size and function in routine practice. Potential underestimation of LA volume and LV mass, and of LVEF in patients with LVEF <50%, should be taken into consideration.

Does High-Intensity Endurance Training Increase the Risk of Atrial Fibrillation? A Longitudinal Study of Left Atrial Structure and Function

BACKGROUND

Exercise mitigates many cardiovascular risk factors associated with atrial fibrillation. Endurance training has been associated with atrial structural changes which can increase the risk for atrial fibrillation. The dose of exercise training required for these changes is uncertain. We sought to evaluate the impact of exercise on left atrial (LA) mechanical and electrical function in healthy, sedentary, middle-aged adults.

METHODS

Sixty-one adults (52±5 years) were randomized to either 10 months of high-intensity exercise training or yoga. At baseline and post-training, all participants underwent maximal exercise stress testing to assess cardiorespiratory fitness, P-wave signal-averaged electrocardiography for filtered P-wave duration and atrial late potentials (root mean square voltage of the last 20 ms), and echocardiography for LA volume, left ventricular end-diastolic volume, and mitral inflow for assessment of LA active emptying. Post-training data were compared with 14 healthy age-matched Masters athletes.

RESULTS

LA volume, Vo₂ max, and left ventricular end-diastolic volume increased in the exercise group (15%, 17%, and 16%, respectively) with no change in control (P<0.0001). LA active emptying decreased post-exercise versus controls (5%; P=0.03). No significant changes in filtered P-wave duration or root mean square voltage of the last 20 ms occurred after exercise training. LA and left ventricular volumes remained below Masters athletes. The athletes had longer filtered P-wave duration but no difference in the frequency of atrial arrhythmia.

CONCLUSIONS

Changes in LA structure, LA mechanical function, and left ventricular remodeling occurred after 10 months of exercise but without significant change in atrial electrical activity. A longer duration of training may be required to induce electrical changes thought to cause atrial fibrillation in middle-aged endurance athletes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02039154.

Assessment of left atrial volume in dogs: comparisons of two-dimensional and real-time three-dimensional echocardiography with ECG-gated multidetector computed tomography angiography

INTRODUCTION

We hypothesized that real-time three-dimensional echocardiography (RT-3DE) was superior to two-dimensional echocardiography for the estimation of left atrial volume (LAV), using electrocardiographic (ECG)-gated multidetector computed tomography angiography (MDCTA) as a volumetric gold standard. The aim was to compare maximum LAV (LAV_max) and minimum LAV (LAV_min) measured by biplane area-length method (ALM), biplane method of disk (MOD) and RT-3DE with 64-slice ECG-gated MDCTA in dogs ANIMALS: The study included twenty dogs, anaesthetized for various diagnostic purposes and without evidence of cardiovascular disease.

METHODS

Left atrial volume was estimated by ALM, MOD and RT-3DE following ECG-gated MDCTA. The results were compared with LAV from MDCTA and correlations were performed. The limits of agreement (LoA) between methods were evaluated using Bland-Altman analysis and intraclass correlations. Coefficients of variation were calculated.

RESULTS

Area-length method (r = 0.79 and 0.72), MOD (r = 0.81 and 0.70) and RT-3DE (r = 0.94 and 0.82) correlated with MDCTA for LAV_max and LAV_min, respectively (all p < 0.05). Biases for LAV_max (-0.96 mL, 95% LoA: -5.6 to 3.7) and LAV_min (-0.67 mL, 95% LoA: -5.4 - 4.1) were minimal with RT-3DE, reflecting a slight underestimation. Conversely, MOD (LAV_maxbias = 3.19 mL, 95% LoA: -5.7 - 12.1; LAV_minbias = 1.96 mL, 95% LoA: -4.6 - 8.5) and ALM (LAV_maxbias = 4.05, 95% LoA: -5.7 - 13.8; LAV_minbias = 2.80 mL, 95% LoA: -3.9 - 9.5) suggested LAV overestimation. Intraobserver and interobserver variability were adequate.

CONCLUSIONS

Real-time three-dimensional echocardiography is a non-invasive, accurate and feasible method with superior accuracy to two-dimensional methods.

Left atrial volume quantification using coronary calcium score scan: Feasibility, reliability and reproducibility analysis of a standardized approach

BACKGROUND

Left atrial volume (LAV) is an independent prognosticator of cardiovascular events. We investigated whether LAV could be accurately and reliably measured using coronary calcium score (CAC) scan.

METHODS

We retrospectively selected consecutive patients that underwent coronary CT angiography (CCTA) and CAC scans. A standardized approach to calculate LAV on images was implemented. The measurements of the LAV on CAC scans and CCTA were performed one to three weeks apart in a random fashion by two readers blinded to the results of each other. The LAV measurements from CAC scan were compared to those from CCTA using correlation analysis. Inter-observer and intra-observer agreement of LAV measurement using CAC scan was evaluated.

RESULTS

Final analysis included one hundred subjects, mean age 52 ± 12 years, 48% male. There was a trend of a marginally larger, albeit not clinically significant, mean LAV calculated using CAC scan compared to that using CCTA: 74.3 vs. 71.0 mL: p < 0.001; for reader 1, and 71.7 vs. 71.2 mL p = 0.06 for reader 2, respectively. LAV using CAC scan and CCTA were highly correlated (R = 0.954, p < 0.001 for reader1 and R = 0.945, p < 0.001 for reader 2). There was high reproducibility within each reader with ICC of 0.951 and 0.989 for readers 1 and 2, respectively (p < 0.001). Finally, there was high inter-observer agreement as indicated by R of 0.97 and ICC of 0.96 (p < 0.001 for both).

CONCLUSIONS

Quantification of LAV from CAC scan using the proposed standardized approach is feasible, highly reliable and reproducible as compared to CCTA.

Left atrial volume index: Can it provide additional prognostic information in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention?

INTRODUCTION

We sought to assess the prognostic impact of left atrial (LA) size on long-term outcomes of ST-segment elevation myocardial infarction (STEMI).

METHODS

We studied 200 consecutive patients admitted to a single center between January 2010 and December 2014 with non-fatal STEMI treated with primary percutaneous coronary intervention (pPCI) who underwent a comprehensive echocardiographic examination at discharge. LA volume was estimated by the area-length method. The left atrium was classified as normal, mildly, moderately or severely enlarged by LA volume index (LAVI). The endpoints were defined as all-cause mortality, a cardiac composite endpoint (all-cause mortality, reinfarction, unplanned revascularization and hospitalization for heart failure) and a cardiovascular composite endpoint (cardiac endpoint plus atrial fibrillation and ischemic stroke) during follow-up.

RESULTS

In this STEMI population, 58% had normal LA size, 22.5% had mild LA enlargement, 10% had moderate LA enlargement and 9.5% had severe LA enlargement. During a median follow-up of 28 (IQR 21-38) months, 14 (7.0%) patients died, 53 (26.5%) had the cardiac and 58 (29%) the cardiovascular composite endpoints. There was a stepwise increase in the incidence of all-cause mortality (p=0.020) and both cardiac (p<0.001) and cardiovascular (p<0.001) endpoints with each increment of LAVI class. In multivariate analysis, severe LA enlargement by LAVI was an independent predictor of all-cause mortality (HR: 11.153; 95% CI: 1.924-64.642, p=0.007) and the cardiac (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) and cardiovascular (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) endpoints during follow-up.

CONCLUSIONS

This contemporary study confirms the prognostic effect of LA size at discharge, applying the most recent reference values in STEMI patients treated with pPCI.

Multimodality Cardiac Imaging for the Assessment of Left Atrial Function and the Association With Atrial Arrhythmias

Several cardiac imaging modalities are able to visualize the left atrium (LA) and, therefore, allow for quantification of both structural and functional properties of this cardiac chamber. In echocardiography, only the maximal LA volume is included in the assessment of diastolic function at the current moment. Numerous studies, however, have shown that functional measures may be superior to the maximal LA volume in several aspects and to possess clinical value even in the absence of structural abnormalities. Such functional measures could prove particularly useful in the setting of predicting atrial fibrillation, which will be a point of focus in this review. Pivotal cardiac magnetic resonance imaging studies have revealed high correlation between LA fibrosis and risk of atrial fibrillation recurrence after catheter ablation, and subsequent multimodality imaging studies have uncovered an inverse relationship between LA reservoir function and degree of LA fibrosis. This has sparked an increased interest into the application of advanced imaging modalities, including both speckle tracking echocardiography and tissue tracking by cardiac magnetic resonance imaging. Even though increasing evidence has supported the use of functional measures and proven its superiority to the maximal LA volume, they have still not been adopted in clinical guidelines. The reason for this discrepancy may rely on the fact that there is little to no agreement on how to technically perform deformation analysis of the LA. Such technical considerations, limitations, and alternate imaging prospects will be addressed in this review.

Murine Echocardiography of Left Atrium, Aorta, and Pulmonary Artery

The present methodology teaches the investigator how to measure and use the LAV as a surrogate of chronic elevations in Left Ventricular diastolic pressure through echocardiography, as well as to obtain measurements of the Aorta and PA diameter in mice. Mice older than 10 d of age can be analyzed using the present technique. The technique is composed of 3 main steps: set-up, image acquisition, and image analysis. The set-up step consists of getting the mouse anesthetized with 1% isoflurane, shaving it, and taping it in a supine position to a heated EKG board where the image acquisition will take place. The image acquisition step consists of learning to identify the cardiac structures and obtaining all the required images with its correspondent probe and axis in order to be able to calculate volumes and diameters. The image analysis step consists of measuring the previously acquired images with the aid of computer software. Advantages of the proposed technique include a fast (15 min) procedure that would allow the researcher to evaluate interventions in a non-invasive, non-terminal approach and therefore follow the same mouse over time; each mouse can be used as its own control. This fact plus having the same operator perform all the acquisition and analysis for the entire experiment minimizes the limitation of operator-dependency. The present methodology is useful for mouse researchers in cardiovascular and pulmonary medicine.

Assessment of left atrial volume and mechanical functions using real-time three-dimensional echocardiography in patients with mitral annular calcification

Objective:

Mitral annular calcification (MAC) is degeneration of the fibrous annular ring of the mitral valve. Left atrial (LA) function and volume have been evaluated by many methods; however, none have used real-time three-dimensional echocardiography (RT3DE) in patients with MAC. Our study is the first to evaluate LA volume and mechanical function using RT3DE in patients with MAC.

Methods:

Our study was a prospective cross-sectional study. In total, 32 patients with echocardiographic evidence of MAC and 30 volunteers without MAC were enrolled in the study. Kolmogorov–Smirnov test, Student’s t-test, Mann-Whitney U test, chi-square test, Pearson’s correlation test, and multiple linear regression analyses were used in this study.

Results:

LA diameter was significantly higher in patients with MAC (38.5±3.8 vs. 31.1±2.9, p<0.001). Maximum LA volume (49.6±11.2 vs. 35.6±2.5, p<0.001), minimum LA volume (23.8±7.9 vs. 12.6±2.3, p<0.001), and LA volume index (LAVI) (26.9±6.1 vs. 20.5±2.4, p<0.001) were also higher in the MAC group. LAVI was correlated with age (p<0.001), blood urea nitrogen levels (p=0.089), total cholesterol levels (p=0.055), left ventricular systolic myocardial velocity (p=0.048), E/A ratio (p<0.001), and MAC (p<0.001). Multiple linear regression analyses revealed that age (β=0.390, p<0.001) and MAC (β=0.527, p<0.001) were independent predictors of LAVI.

Conclusion:

We found that LA mechanical function was impaired in patients with MAC. Furthermore, age and MAC were independent predictors of increased LAVI according to our RT3DE examination.

The differences in left atrial function between ischemic and idiopathic dilated cardiomyopathy patients: A two-dimensional speckle tracking imaging study

PURPOSE

To evaluate left atrial (LA) function in patients with ischemic (ICM) or idiopathic dilated (DCM) cardiomyopathy via two-dimensional speckle-tracking imaging.

METHODS

We measured the LA maximum volume, minimum volume, and volume before the atrial systole, and calculated total emptying volume, expansion index, active emptying volume, and fraction. We measured strain and strain rate during systole and late diastole using two-dimensional speckle-tracking imaging, and analyzed correlations between variables.

RESULTS

We found no significant differences in LA size, left ventricle (LV) end-diastole diameter, LV ejection fraction (EF), E/A, E/e', deceleration time of the E wave, and effective mitral regurgitant orifice area between the DCM and the ICM group. However, the LA expansion index, active EF, systolic and late diastolic strain, and strain rate were lower in the ICM group (p < 0.05). The expansion index and active EF were positively correlated with the systolic strain rate and the absolute value of the late diastolic strain rate, respectively.

CONCLUSIONS

LA basic echocardiographic variables did not reflect the differences between ICM and DCM patients, but the systolic and late diastolic strain, as well as the strain rate, were lower in DCM patients. Two-dimensional speckle-tracking imaging is a promising method to differentiate these patients. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:437-445, 2016.

Volume Measurements in Aortic Root Assessment Using Two-Dimensional Echocardiography

BACKGROUND

Aortic dilatation is associated with the presence of aortic diseases. Current guidelines for assessing the aortic root (AoR) depend on linear measurements acquired by two-dimensional (2D) echocardiography. We considered that real-time three-dimensional echocardiography, which correlates better with AoR volume obtained by computed tomography, is widely unavailable, and therefore, there is a need to determine the AoR volume using 2D echocardiography.

METHODS

Fifty-one consecutive apparently healthy volunteers were recruited and subsequently divided into three age groups. Specified planes of acquisition and previously defined landmarks were identified, and phases of the cardiac cycle that allowed for measurement standardization were used. Volume was determined by the modified Simpson’s method.

RESULTS

Although the average diastolic and systolic volume measurements of the AoR dimensions were not significantly different across the three age groups in the study population, a highly significant difference was observed in the volume measurements between male and female normotensive persons, P < 0.01 in each case. AoR volume measurements were five times in the diseased compared with the normotensive individuals; however, linear measurements were only 1.5 times in size of the normal individuals. Both point and interval estimates of the volume measurements of AoR in adult normotensives in three age groups were presented as baseline information.

CONCLUSIONS

We hereby present a novel way to determine the AoR volume using 2D echocardiography and the normal reference range with respect to age and gender. We also established the relevance of our measurement by comparing the normal population with two isolated diseased aortas.

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. The present review summarizes the recent advances in the field of echocardiography, with emphasis on their role in HF phenotyping, risk stratification, and optimizing clinical outcomes.

Left Atrial Volumes and Function by Three-Dimensional Echocardiography

Background—

Our study sought to (1) identify reference values for left atrial (LA) volumes and phasic function indices by 3-dimensional echocardiography (3DE) and compare them with those measured by 2-dimensional echocardiography (2DE) and (2) analyze their relationship with age, sex, body size, and left ventricular function. Accuracy and reproducibility of 3DE and 2DE have been also tested to evaluate the robustness of our data.

Methods and Results—

We obtained maximal, minimal, and preA LA volumes by 3DE and 2DE in 276 healthy volunteers (18–79 years; 57% women). Limits of normality for LA volumes and total LA emptying fraction were larger with 3DE than with 2DE (maximal LA volume: 43 versus 35 mL/m 2 ; preA LA volume: 31 versus 25 mL/m 2 ; minimal LA volume: 18 versus 14 mL/m 2 ; 53 versus 48%, respectively; P <0.001). 3DE LA volumes indexed by body surface area were similar in men and women and increased with age. On multivariable analysis, age, weight, and left ventricular systolic and diastolic function indices resulted as correlates of LA 3DE indices. LA volumes were tightly correlated with cardiac magnetic resonance measurements, yet more underestimated by 2DE versus 3DE (bias±SD: −17±16 versus −7±15 mL, respectively). Among all LA parameters, maximal LA volume and total emptying fraction were the most reproducible, including at test-retest and at expert versus trainee comparisons.

Conclusions—

This study provides reference values for LA 3DE volumes and function from a relatively large cohort of healthy subjects with a wide age range. Our data may help clinicians to identify LA remodeling and dysfunction.

The mitral annular displacement by two-dimensional speckle tracking: a new tool in evaluating the left atrial function

BACKGROUND

The methods used to characterize the volume change and the deformation of the left atrium are highly dependent on technical factors and difficult to use in a clinical environment. The aim of this study was to demonstrate that mitral annular displacement by speckle tracking can be an alternative method to studying the longitudinal left atrial function.

METHODS

Ninety study participants (54% men), with a mean age of 53(±15) years, underwent a complete echocardiographic examination, comprising two-dimensional, three-dimensional and tissue Doppler imaging (TDI). They were divided into normal individuals (35) and patients having an abnormal echocardiography (55).

RESULTS

There was a very strong correlation between three-dimensional volumetric function and mitral annular displacement, both for the reservoir (r = 0.78; P < 0.0001) and contractile (r = 0.76; P < 0.0001) functions. The correlation with the longitudinal strain displayed an r = 0.87, P > 0.0001 for the reservoir and r = 0.81, P < 0.0001 for the contractile function. The systolic speed in pulsed TDI and the systolic displacement had an r = 0.83, P < 0.0001. Mitral annular displacement was a very good discriminator for normal versus abnormal participants [area under the curve (AUC) for reservoir = 0.872 and for contractile = 0.843; P < 0.0001], performing less well than three-dimensional (AUC reservoir = 0.892 and contractile = 0.915; P < 0.0001) or deformation (AUC = 0.921 and 0.903 respectively; P < 0.0001), but better than pulsed TDI (AUC = 0.807; P < 0.0001). The percentage error was ±15% for interobserver and ±12% for intraobserver variability. The time taken for displacement analysis was 9 ± 3 s for an experienced cardiologist and 12 ± 4 s for a beginner.

CONCLUSION

Mitral annular displacement by speckle tracking is a reliable and fast method to evaluate left atrial function. Given the strength of the correlations with strain parameters, it could be used as a surrogate measure of the deformation of left atrium.

Diagnostic Evaluation and Follow-Up of Patients with Atrial Fibrillation

In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Left Atrial Volume and Pulmonary Artery Diameter Are Noninvasive Measures of Age-Related Diastolic Dysfunction in Mice

Impaired cardiac diastolic function occurs with aging in many species and may be difficult to measure noninvasively. In humans, left atrial (LA) volume is a robust measure of chronic diastolic function as the LA is exposed to increased left ventricular filling pressures. We hypothesized that LA volume would be a useful indicator of diastolic function in aging mice. Further, we asked whether pressures were propagated backwards affecting pulmonary arteries (PAs) and right ventricle (RV). We measured LA, PA, and RV infundibulum dimensions with echocardiography and used mouse-specific Doppler systems and pressure catheters for noninvasive and invasive measures. As C57BL/6 mice aged from 3 to 29-31 months, LA volume almost tripled. LA volume increases correlated with traditional diastolic function measures. Within groups of 14- and 31-month-old mice, LA volume correlated with diastolic function measured invasively. In serial studies, mice evaluated at 20 and 24 months showed monotonic increases in LA volume; other parameters changed less predictably. PA diameters, larger in 30-month-old mice than 6-month-old mice, correlated with LA volumes. Noninvasive LA volume and PA diameter assessments are useful and state independent measures of diastolic function in mice, correlating with other measures of diastolic dysfunction in aging. Furthermore, serial measurements over 4 months demonstrated consistent increases in LA volume suitable for longitudinal cardiac aging studies.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Automated quantification of left atrial size using three-beat averaging real-time three dimensional Echocardiography in patients with atrial fibrillation

Background

Left atrial (LA) sizing in patients with atrial fibrillation (AF) is crucial for follow-up and outcome. Recently, the automated quantification of LA using the novel three-beat averaging real-time three dimensional echocardiography (3BA-RT3DE) is introduced. The aim of this study was to assess the feasibility and accuracy of 3BA-RT3DE in patients with atrial fibrillation (AF).

Methods

Thirty-one patients with AF (62.8 ± 11.7 years, 67.7 % male) were prospectively recruited to have two dimensional echocardiography (2DE) and 3BA-RT3DE (SC 2000, ACUSON, USA). The maximal left atrial (LA) volume was measured by the conventional prolate-ellipse (PE) and area-length (AL) method using three-beat averaging 2D transthoracic echocardiography and automated software analysis (eSie volume analysis, Siemens Medical Solution, Mountain view, USA); measurements were compared with those obtained by computed tomography (CT).

Results

Maximal LA volume by 3BA-RT3DE was feasible for all patients. LA volume was 68.4 ± 28.2 by PE-2DE, 89.2 ± 33.1 by AL-2DE, 100.6 ± 31.8 by 3BA-RT3DE, and 131.2 ± 42.2 mL by CT. LA volume from PE-2DE (R² = 0.48, p < 0.001, ICC = 0.64, p < 0.001), AL-2DE (R² = 0.47, p < 0.001, ICC = 0.67, p < 0.001), and 3BA-RT3DE (R² = 0.50, p = 0.001, ICC = 0.65, p < 0.001) showed significant correlations with CT. However, 3BA-RT3DE demonstrated a small degree of underestimation (30.5 mL) of LA volume compared to 2DE-based measurements. Good-quality images from 3BA-RT3DE (n = 16) showed a significantly tighter correlation with images from CT scanning (R² = 0.60, p = 0.0004, ICC = 0.76, p < 0.001) compared to those of fair quality.

Conclusion

Automated quantification of LA volume using 3BA-RT3DE is feasible and accurate in patients with AF. An image of good quality is essential for maximizing the value of this method in clinical practice.

Evaluation of left atrial volume and function in systemic sclerosis patients using speckle tracking and real-time three-dimensional echocardiography

Objective:

The aim of the present study was to evaluate left atrial (LA) volume and functions using real-time three-dimensional echocardiography (RT3DE) and speckle tracking in systemic sclerosis (SSc) patients.

Methods:

The study was designed as a cross-sectional observational study. We studied 41 consecutive SSc patients (38 females, mean age: 49.5±11.6 years) and 38 healthy controls (35 females, mean age: 48.5±10.8 years). Patients with evidence or history of cardiovascular disease and patients with risk factors as hypertension, diabetes and chronic renal failure were excluded from the study. All study subjects underwent standard echocardiography; LA speckle tracking and RT3DE was performed to assess LA volume and phasic functions. Differences between numeric variables were tested using the independent sample Student’s t-test or Mann-Whitney U test, where appropriate.

Results:

There were no significant differences between SSC patients and controls regarding left ventricular (LV) systolic functions and two-dimensional (2-D) atrial diameters. Presence of LV diastolic dysfunction (LVDD) was evaluated and graded according to recommendations of the American Society of Echocardiography. Accordingly, LVDD was observed to be significantly more frequent in SSc patients; 16 SSc patients (39%) and 5 controls (12.8%) were observed to have LVDD (p=0.007). With regard to results obtained from RT3DE, LA maximum, minimum, and before atrial contraction volumes were significantly higher (40.5±14.6 vs. 32.6±8.9, 15.5±8.4 vs. 9.9±3.5 and 28.7±11.7 vs. 21.4±7.0 mL respectively, p<0.05 for all), whereas LA active emptying fraction, LA total emptying fraction, LA expansion index, and passive emptying fraction values were significantly (47.1±12.0 vs. 52.9±10.1%, 62.8±10.5 vs. 69.5±6.7%, 187.5±76.0 vs. 246.6±96.0, 29.6±9.3 vs. 34.4±11.0% respectively, p<0.05 for all) in SSc patients than in controls. In addition, regarding results obtained from speckle tracking echocardiography, atrial peak-systolic longitudinal strain (e), early negative strain rate (SR), late negative SR, and peak positive SR values were observed to be significantly lower in SSc patients.

Conclusion:

LA volumes were significantly increased, and LA reservoir, conduit, and contractile functions were significantly impaired in SSc patients compared with controls. LA volume and functional analyses with RT3DE and speckle tracking may facilitate the recognition of subtle LA dysfunction in SSc patients.

Role of echocardiography in clinical hypertension

Hypertension is a major and correctable cardiovascular risk factor. The correct diagnosis of hypertension and precise assessment of cardiovascular risk are essential to give proper treatment in patients with hypertension. Although echocardiography is the second-line study in the evaluation of hypertensive patients, it gives many clues suggesting bad prognosis associated with hypertension, including increased left ventricular (LV) mass, decreased LV systolic function, impaired LV diastolic function, and increased left atrial size and decreased function. Along with conventional echocardiographic methods, tissue Doppler imaging, three-dimensional echocardiography, and strain echocardiography are newer echocardiographic modalities in the evaluation of hypertensive patients in the current echocardiographic laboratories. Understanding conventional and newer echocardiographic parameters is important in the diagnosis and assessment of cardiovascular risk in hypertensive patients.

Prognostic significance of NT-proBNP, 3D LA volume and LV dyssynchrony in patients with acute STEMI undergoing primary percutaneous intervention

OBJECTIVES

The aim of the present study was to assess the short term prognostic significance of N-terminal pro BNP (NT-proBNP), 3D left atrial volume (LAV) and left ventricular (LV) dyssynchrony in patients of acute ST-elevation myocardial infarction (STEMI) who underwent primary Percutaneous intervention (PCI).

BACKGROUND

NT-proBNP, LV dyssynchrony and LAV in patients with acute coronary syndrome have been associated with PCI outcomes and predict the short and long-term prognosis.

METHODS

This study consisted of 142 patients with a first STEMI who underwent primary PCI. Baseline echocardiographic data was collected at admission and at 6 months follow up. Left ventricular dyssynchrony was measured by tissue Doppler imaging and LAV by real time 3D-echocardiography, plasma NT-proBNP levels were estimated between 72 and 96 h of admission.

RESULTS

During study period 3 patients expired and 4 developed congestive heart failure (CHF). Baseline NT-proBNP and LV dyssynchrony correlated with LV size and LV ejection fraction (LVEF) at baseline and during follow up. Patients with higher NT-proBNP levels and higher LV dyssynchrony showed significant increase in LV size with decrease in LVEF during follow-up. Baseline Left atrial volume index (LAVI) showed significant correlation with LV size but no association with LVEF at baseline and during follow-up.

CONCLUSIONS

Higher levels of NT-proBNP and higher LV dyssynchrony can predict patients with increase in LV size, worsening of LV systolic and diastolic function during follow-up. Patients with higher NT-proBNP levels at baseline developed CHF during follow-up.

Left atrial volumes: two-dimensional, three-dimensional, cardiac magnetic resonance and computed tomography measurements

PURPOSE OF REVIEW

Evaluation of left atrial volume is important, as it is a biomarker of cardiovascular disease and outcomes and correlates with diastolic dysfunction severity. Left atrial volume measurements by different imaging modalities, including 2D and 3D echocardiography (2DE and 3DE), cardiac magnetic resonance (CMR) and computed tomography (CT), are reviewed in regard to recent advances, methodology, prognostic value and limitations.

RECENT FINDINGS

Left atrial volume assessments correlate well between the different imaging modalities; however, 2DE significantly underestimates left atrial measurements. Assessment of the left atrial minimum volume and left atrial phasic function derived volumetrically have reported superior predictive value for major adverse cardiovascular events and elevated left ventricular diastolic pressure compared with the left atrial maximum volume.

SUMMARY

The different imaging modalities used to assess left atrial volumes are not interchangeable, particularly for serial measurements. Although 2DE underestimates left atrial volumes, most normative as well as predictive data have been obtained using this modality. Standardization, with established normative data and classification criteria, needs to be established for other imaging modalities, additionally incorporating assessment of left atrial minimum and phasic volumes. Despite the limitations of the more simplistic 2DE, its measurements are well defined with significant prognostic value. The incremental prognostic value of the more complex imaging techniques needs to be further validated.

Left atrial volume assessment in atrial fibrillation using multimodality imaging: a comparison of echocardiography, invasive three-dimensional CARTO and cardiac magnetic resonance imaging

Left atrial size in atrial fibrillation is a strong predictor of successful ablation and cardiovascular events. Cardiac magnetic resonance multislice method (CMR-MSM) is the current gold standard for left atrial volume (LAV) assessment but is time consuming. We investigated whether LAV with more rapid area-length method by echocardiography (Echo-AL) or cardiac magnetic resonance (CMR-AL) and invasive measurement by 3D-CARTO mapping during ablation correlate with the CMR-MSM. We studied 250 consecutive patients prior to atrial fibrillation ablation. CMR images were acquired on 3T scanner to measure LAV by MSM and biplane area-length method. Standard echocardiography views were used to calculate LAV by biplane area-length method. LAV during ablation was measured by 3D-CARTO mapping. LAV was compared using intra-class correlation (ICC), Pearson's correlation and Bland-Altman plots. CMR-MSM was used as the reference standard. Mean LAV using CMR-MSM was 112.7 ± 36.7 ml. CMR-AL method overestimated LAV by 13.3 ± 21.8 ml (11.2%, p < 0.005) whereas 3D-CARTO and Echo-AL underestimated LAV by 8.3 ± 22.6 and 24.0 ± 27.6 ml respectively (8.7% and 20.0% respectively, p < 0.005). There was no significant difference between paroxysmal and persistent atrial fibrillation. CMR-AL and 3D-CARTO correlated and agreed well with CMR-MSM (r = 0.87 and 0.74, ICC = 0.80 and 0.77 respectively). However, Echo-AL had poor correlation and agreement with CMR-MSM (r = 0.66 and ICC = 0.48). Bland-Altman plots confirmed these findings. CMR-AL method may be used as an alternative to CMR-MSM, as it is non-invasive, rapid, and correlates well with CMR-MSM. LAV by different modalities should not be used interchangeably.

Diagnostic evaluation and follow-up of patients with atrial fibrillation

In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.

Effects of diabetes mellitus on left atrial volume and functions in normotensive patients without symptomatic cardiovascular disease

PURPOSE

Left atrial (LA) size has been shown to be a predictor of adverse cardiovascular outcomes. The aim of the study was to evaluate the direct effect of diabetes mellitus (DM) on left atrial volume and phasic functions by using real-time three-dimensional echocardiography (RT3DE) in a population of patients free of symptomatic cardiovascular disease and hypertension.

METHODS

Comprehensive transthoracic echocardiographic examination was performed on 40 consecutive patients with DM (20 male, age: 50.5±7.3 years) and 40 healthy controls (20 male, age: 48.4±6.7 years). In addition to conventional 2D echocardiographic measurements RT3DE was performed to assess LA volumes and phasic functions.

RESULTS

There were no significant difference between groups regarding parameters reflecting LV systolic function as LV diameters and ejection fraction. However, regarding parameters reflecting LV diastolic function; transmitral deceleration time and E/E' ratio values were significantly higher and majority of early diastolic tissue Doppler velocity values were significantly lower in diabetic patients compared with controls. RT3DE demonstrated significantly higher LA maximum and minimum volumes for diabetic patients compared with controls (40.9±11.9 vs 34.6±9.3 mL, p: 0.009 and 15.6±5.9 vs 11.9±4.6 mL, p: 0.002, consecutively). LA total emptying fraction (TEF), expansion index (EI) and active emptying fraction (AEF) were found to be significantly lower in diabetics reflecting depressed LA reservoir and pump functions. There was no significant difference between groups regarding passive emptying fraction (PEF) which is assumed to be a marker of left atrial conduit function.

CONCLUSION

Patients with type 2 diabetes mellitus were found to have increased LA volume and impaired atrial compliance and contractility. Evaluation of asymptomatic diabetic patients by using RT3DE atrial volume analysis may facilitate recognition of subtle myocardial alterations related with type 2 diabetes.