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3.4.3 Left atrial size

Left atrial enlargement is either the result of elevated atrial
pressure or an increase in flow. However, the degree of left
atrial enlargement depends on the compliance of the left
atrial wall. This is why you might see patients with fairly
high atrial pressures but only modest enlargement of the left
atrium, or vice versa. Another important factor that
contributes to atrial enlargement is atrial fibrillation. Atrial
fibrillation leads to "scarring" of the atrial wall and
ultimately to (further) dilatation of the left atrium.

Disproportionate enlargement of the left atrium (in relation

to the left ventricle) in athletes may be a clue to the presence
of myocardial disease
 

0:02

Normal LA

0:02

Dilated LA

In many cases it will be quite obvious from the 2D image that

the atrium is enlarged. If left atrial pressure is also high you
will see the interatrial septum bulging to the right and
expansion of the left atrial appendage. The atrium may
become quite huge, especially in mitral stenosis and
restrictive cardiomyopathy. The largest atrium I encountered
had a volume of more than 800 ml.

Visual assessment of size provides a first rough estimate. It is

essential to perform measurements. Previously, the MMode
from a parasternal long axis was used to quantify the left
atrium. This diameter represents the anterior posterior
dimension of the left atrium. A diameter of < 40 mm and a
ratio left atrium/aortic root of < 1.3 are considered normal.
The major problem of the MMode is that perpendicular
orientation to the left atrium may not be possible. Therefore,
2-D measurements have now replaced the MMode.
Measurements should be performed in apical views (four-
and two-chamber view) during end-systole.

Avoid foreshortening of the left atrium.

Both the length and the width of the left atrium can be
determined here. However, make sure you perform the
measurements more or less parallel to the interatrial septum
from the plane of the mitral annulus to the roof of the
atrium, and do not include the right upper pulmonary vein.

2D measurements are very simple to obtain and fairly

reliable. Still, the preferred method to quantify left atrial size
is now volumetric methods because they also account for
variations in the shape of the left atrium. There are two
different principles with which volumes can be obtained: the
area-length method and the method of discs (Simpson
method). For both methods, tracing of the atrial cavity is
required. This is done on a four chamber view at end systole,
shortly before the mitral valve opens. For the biplane
approach, which is even more exact, also use a 2-chamber
view.

Include a septal aneurysm but not the left atrial appendage

or the pulmonary veins in your tracing of the left atrium.

The area length method is based on a geometric assumption

and employs the following formula:

Area length formula to calculate left atrial volume

The Simpson method uses the rule of discs, which has

already been described for the left ventricle (see: 3.2.3.2 2
The Simpson method to determine ejection fraction).

Most measurement programs automatically derive both

volume computations (in ml). The area length method is
probably a little less exact than the Simpson method, but
both can be used because they yield very similar results. All
of the measurements can then be indexed to the body
surface area.
 Inclusion of pulmonary veins Inclusion of tenting area

Alignment / foreshortening Lateral resolution

not at end-systole

Pitfalls

Left atrial volume is a strong predictor of events. There is

evidence that patients with left atrial volumes above 34 ml
per m2 are at high risk for ischemic stroke, heart failure,
atrial fibrillation, and death.

Volume calculations can also be performed with 3D

technologies. Although this approach is mainly used in
research and has not reached clinical practice yet, it might
be the method of the future.

Normal (mm) 30—40 27—38

Mild (mm) 41—46 39—42

Moderate (mm) 47—52 43—46

Severe (mm) ≥ 52 ≥ 47

MMode Measurements of LA — Reference Values

Normal (mm) ≤ 50

Mild (mm) 51—60

Moderate (mm) 61—70

Severe (mm) > 70

LA Length — Reference Values

 Normal (cm2) ≤ 20

Mild (cm2) 20—30

Moderate (cm2) 30—40

Severe (cm2) > 40

LA Area

Normal (mL) 18- 58 22- 52

Mild (mL) 59- 68 53- 62

Moderate (mL) 69- 78 63- 72

Severe (mL) ≥ 79 ≥ 73

LA Volume
Normal (mL/m2) 22±6

Mild (mL/m2) 28-33

Moderate (mL/m2) 34-40

Severe (mL/m2) > 40

Indexed LA Volume

‹ 3.4.2 Anatomy and function of the left atrium

up

3.4.4 Left atrial function ›

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