CARDIOVASCULAR

ULTRASOUND

Novel echocardiographic techniques to assess left

atrial size, anatomy and function
Cameli et al.

Cameli et al. Cardiovascular Ultrasound 2012, 10:4

http://www.cardiovascularultrasound.com/content/10/1/4 (1 February 2012)

Cameli et al. Cardiovascular Ultrasound 2012, 10:4

http://www.cardiovascularultrasound.com/content/10/1/4

CARDIOVASCULAR
ULTRASOUND

REVIEW

Open Access

Novel echocardiographic techniques to assess left

atrial size, anatomy and function
Matteo Cameli*, Matteo Lisi, Francesca Maria Righini and Sergio Mondillo

Abstract
Three-dimensional echocardiography (3DE) and speckle tracking echocardiography (STE) have recently applied as
imaging techniques to accurately evaluate left atrial (LA) size, anatomy and function. 3DE and off-line quantification
softwares, have allowed, in comparison to magnetic resonance imaging, the most time-efficient and accurate
method of LA volume quantification. STE provides a non-Doppler, angle-independent and objective quantification
of LA myocardial deformation. Data regarding feasibility, accuracy and clinical applications of LA analysis by 3DE
and STE are rapidly gathering. This review describes the fundamental concepts of LA 3DE and STE, illustrates how
to obtain respective measurements and discuss their recognized and emerging clinical applications.
Keywords: Echocardiography, Left atrium, Three-dimensional echocardiography, Speckle tracking, Strain

Background
The progress of echocardiography has gone hand in hand
with the growth of knowledge of the function and role of
the left atrium in cardiovascular disease. Echocardiography
started from information about the shape and size of the
atrium: first with M-mode technique, then with twodimensional measurement of the area and then with the
assessment of atrial systolic volumes. However, even
though the clinical importance of left atrial (LA) size and
function has always been well known, its assessment has
been neglected for some time due to the lack of tools able
to assess a complete evaluation of its anatomy and performance. Recent population-based studies have demonstrated the prognostic value of LA analysis for long-term
outcome. In fact, LA structural and functional remodeling
has been proposed as a barometer of diastolic burden and
a predictor of common cardiovascular outcomes such as
atrial fibrillation, stroke, congestive heart failure, and cardiovascular death [1-3]. The structural and functional analysis of LA reflects a spectrum of pathophysiological
changes that have occurred in response to specific stressors; in fact, the left atrium is exposed directly to left ventricular diastolic pressure through the open mitral valve
and because of its thin wall structure it tends to reduce its
elastic properties and finally to dilate with increasing
pressure.
* Correspondence: cameli@unisi.it
Department of Cardiovascular Diseases, University of Siena, Italy

Herein, we present an overview of two novel echocardiographic techniques, three-dimensional echocardiography

(3DE) and speckle tracking echocardiography (STE) [4],
that have evolved recently and have conferred new insight
into LA structural and functional mechanics, paying attention to describe the technological aspects and the advantages and limitations of both these techniques.

Three-dimensional echocardiography
LA size assessment represents a significant predictor of
morbidity and mortality in many cardiovascular conditions [5,6]; it has been shown recently that indexed LA
volume is a more robust cardiovascular risk marker than
LA area or diameter [7].
Even if 2D echocardiography remains the current
standard in clinical practice for the assessment of LA
size [8], the use of real-time three-dimensional echocardiography (RT3DE) has been recently introduced as a
new technique for the assessment of LA volume and LA
ejection fraction (LAEF).
Methods

LA volumes by RT3DE is collected in four-cycles fullvolume made during a breath hold, using a 3D matrixarray transducer. Acquisition is triggered to the electrocardiographic R wave. Particular care is taken to ensure
that the entire LA is included within a pyramidal 3D
data set. The pyramidal volume data is displayed in

2012 Cameli et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
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three different cross-sections that may be modified

interactively by manual shifting of vertical and horizontal lines in the two orthogonal apical and the short-axis
views. LA volume by 3D echocardiography is derived
from semi-automated tracing of the LA endocardium,
starting the measurements in the frame with the largest
atrial dimension, corresponding to ventricular end-systole, just before opening of the atrio-ventricular valves,
in perpendicular apical long-axis planes.
This is performed by making 5 points in the atrial surfaces of the mitral annulus: at the anterior, inferior, lateral, and septal annulus, and the fifth point at the apex of
the left atrium. Following this manual identification, the

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program automatically identifies the endocardial surface

using a deformable shell model [9,10]. Then manual
adjustment of the endocardial surface is performed in all
examinations presented, in order to include trabeculae
and to exclude atrial appendages and large veins from
the cavity volumes. Then the frame with the smallest
atrial dimension (at ventricular end-diastole) is selected
with similar surface detection and manual editing.
Atrial maximum (max) and minimum (min) volumes
are obtained, and atrial EF is derived from the two
volumes (Figure 1).
Recently Aune et al. [11] have reported the normal
reference values of LA, right atrial (RA) volumes, and

Figure 1 An example of three-dimensional echocardiographic reconstruction of LA volume (ml) and LA ejection fraction (LAEF%)
measurements by TomTec software, after the acquisition of a full-volume dataset. Delineation of the endocardial border at end-diastole
(A-C) and end-systole (D-F), estimation of LAEF (G), LA volume reconstruction (H) and LA time-volume curves (I).

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LAEF obtained by 3DE in one hundred and sixty-six

healthy subjects, aged 29-79 years. In this study upper
normal values for LA volume and LAEF were similar for
both genders; RA volumes was 15% higher than LA ones
(Table 1).

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potential artifacts are critical and most of all related to

respiratory or ECG gating and/or incorrect gain settings
which are particular challenging in patients with
arrhythmias or respiratory difficulties [19].
Clinical applications

Advantages and limitations

LA volume measurements by RT3DE correlate closely

with those obtained on multidetector computed tomography [10] and on magnetic resonance imaging [12,13],
showing a better diagnostic accuracy respect to 2D
methods [14].
In particular, 3DE reconstruction overcomes 2DE limitations, avoiding geometric assumptions for LA volume
evaluation [15] (Figure 1). The latest generation of 3D
matrix-array transducers and off-line quantification softwares, has allowed, in comparison to MRI, the most
time-efficient method of LA volume quantification, with
the exception of poor image quality or cardiac arrhythmias [13].
Moreover, through 3DE it is possible to estimate LA
ejection fraction (LAEF) (Figure 2); despite recent guidelines did not mention any possible application, several
clinical conditions may require three-dimensional LA
function analysis (Figure 3). Recent reports have shown
potential applications of LAEF in different patterns of
diastolic dysfunction, demonstrating a good correlation
with the E/E ratio [16].
Despite the good correlation between 3DE and MRI in
estimating LA volume, several studies show that echocardiography systematically tends to underestimate LA
volumes when compared to MRI [17,18]. A probable
cause of this disparity is the difference in spatial image
resolution between both 2D and 3DE compared to MRI;
in fact echocardiography presents low lateral image resolution because apical window places the left atrium at the far
field of the ultrasound beam. In addition 2D and 3D ultrasound images could not be able to distinguish the volumes
within the intratrabecular atrial areas [13].
Moreover, as with any new imaging technique, a
learning curve exists, and recognizing and avoiding

3D echocardiography is a safe, non-invasive imaging

modality that may be a very promising tool to assess
atrial size, providing important insights into LA morphologic and functional evaluations.
Recently, it has been shown that LA volume provides
a more accurate measure of LA size than conventional
M-mode LA dimension [20]. In fact LA enlargement
occurs in all 3D directions but not in a uniform fashion
and medial-lateral expansion is less prominent than
longitudinal and antero-posterior expansions, so onedimensional assessment is likely to be an insensitive
assessment of any change in LA size [21]. For these reasons, the ASE has recommended quantification of LA
size by biplane 2D echocardiography.
However, cyclic changes in LA volume may not be
observed directly by two-dimensional echocardiography
because the shape of the left atrium changes during the
heart cycle and generally only maximum LA volume is
routinely measured in clinical practice.
The physiologic volume changes that occur in the different phases of cardiac cycle may be accurately evaluate
by RT3DE; real-time acquisition of 3-dimensional views
during a routine echocardiographic examination allows
us to analyze the dynamic changes in LA volume and to
quantify the contribution of LA to LV filling, calculating
also LA ejection fraction by the 3D semi-automated
software [16].
The relative contribution of LA phasic function to LV
filling is dependent upon the LV diastolic properties;
with increased stiffness or noncompliance of the LV, LA
pressure rises to maintain adequate LV filling, and the
increased atrial wall tension leads to chamber dilatation
and stretch of the atrial myocardium [20]. Thus, LA
volume increases with severity of diastolic dysfunction.
The structural changes of the LA may express the

Table 1 Reference ranges of left and right atrial indexed volumes (LAVI and RAVI) and of ejection fractions of both
atria (LAEF and RAEF) obtained with real-time three-dimensional echocardiography (RT3DE).
RT3DE

Males
(n = 75)

Females
(n = 84)

Total Study Population (n = 159)

LAVI max (ml/m2)

15-42

15-39

15-41

LAVI min (ml/m2)

6-20

5-18

5-19

LAEF (%)

46-77

44-80

45-79

RAVI max (ml/m2)

RAVI min (ml/m2)

18-50
7-22

17-41
5-18

18-47
5-20

RAEF (%)

46-74

48-83

46-80

[Modified from Aune et al. Eur J Echocardiogr 2009;10:738-44]

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Figure 2 Three-dimensional echocardiographic LA reconstruction in a healthy subject: Normal LA volume and normal LAEF.

chronicity of exposure to abnormal filling pressures and

provide predictive information beyond that of diastolic
function grade. In this way, LA volume reflects an average effect of LV filling pressures over time, rather than
an instantaneous measurement at the time of study.
Thus, Doppler and tissue Doppler assessment of instantaneous filling pressure is better suited for monitoring
hemodynamic status in the short term, whereas LA
volume is useful for monitoring long-term hemodynamic
control [20].

Speckle tracking echocardiography

The atrial longitudinal strain, deriving from application
of the analysis of myocardial deformation using STE at
atrial chambers, results the first parameter useful for

functional analysis of the LA and, as shown by recent

studies, it presents considerable feasibility and reproducibility [22-25].
Methods

Two-dimensional strain imaging is an echocardiographic

technique that uses standard B-mode images for speckle
tracking analysis. The speckle pattern (acoustic backscatter generated by the reflected ultrasound beam) is
followed frame-by-frame, using a statistical approach
based on the detection of the best matching area. The
displacement of this speckled pattern is considered to
follow myocardial movement and a change between
speckles is assumed to represent myocardial deformation [4].

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Figure 3 Three-dimensional echocardiographic LA reconstruction in a patient affected by cardiac amylodosis: LA enlargement and
reduced LAEF.

Although this new technique was introduced for the

exclusive analysis of left ventricular (LV) function, several
studied have recently extended its applicability to other
cardiac chamber, such as the left atrium [22,23,26-29].
For speckle tracking analysis of left atrial chamber, apical four- and two-chamber views images are obtained
using conventional two-dimensional gray scale echocardiography, during breath hold with a stable ECG recording. Particular attention is given to obtain an adequate
gray scale image, allowing reliable delineation of myocardial tissue and extracardiac structures. Three consecutive
heart cycles are recorded and averaged. The frame rate is
set between 60 and 80 frames per second; these settings
are recommended to combine temporal resolution with

adequate spatial definition, and to enhance the feasibility

of the frame-to-frame tracking technique [22].
Recordings are processed using an acoustic-tracking
software (Echo Pac, GE, USA), allowing off-line semiautomated analysis of speckle-based strain.
In particular, LA endocardial surface is manually
traced in both four- and two-chamber views by a pointand-click approach. An epicardial surface tracing is then
automatically generated by the system, thus creating a
region of interest (ROI). To trace the ROI in the discontinuity of LA wall corresponding to pulmonary veins
and LA appendage, the direction of LA endocardial and
epicardial surfaces at the junction with these structures
is extrapolated. After manual adjustment of ROI width

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and shape, the software divides the ROI into 6 segments, and the resulting tracking quality for each segment is automatically scored as either acceptable or
non-acceptable, with the possibility of further manual
correction. Segments in which no adequate image quality can be obtained are rejected by the software and
excluded from the analysis. In subjects with adequate
image quality, a total of 12 segments are then analyzed
[22].
Lastly the software generates the longitudinal strain
curves for each segment and a mean curve of all segments that reflect the pathophysiology of atrial function
(Figure 4). During the reservoir phase, the LA fills up,
stretches itself, and for this reason, the atrial strain
increases, reaching a positive peak at the end of atrial
filling, before the opening of the mitral valve; after the
opening of the mitral valve, LA empties quickly, shortens, the strain decreases, up to a plateau corresponding
to the phase of diastasis, followed by a second positive

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peak, but less than the first, which corresponds to the

period preceding the atrial contraction, and finally a
negative peak after the atrial contraction (Figure 4) [22].
This second positive deflection of the atrial strain curve,
corresponding to atrial systole, is present only if the
subject analyzed presents sinus rhythm. Thus, as shown
in Figure 4, peak atrial longitudinal strain (PALS), measured at the end of the reservoir phase, and peak atrial
contraction strain (PACS), measured just before the
start of the active atrial contractile phase, are calculated
by averaging values observed in all LA segments (global
PALS and PACS), and by separately averaging values
observed in four- and two-chamber views (four- and
two-chamber average PALS and PACS, respectively). LA
contraction strain index (CSI), representing, in percentual values, the contribution of the LA active contraction to the LV filling phase, is calculated as (global
PACS/global PALS) 100. The time to peak longitudinal strain (TPLS) is also measured as the average of all

Figure 4 Peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) in a representative subject.

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12 segments (global TPLS) and by separately averaging

values observed in the two apical views (four- and twochamber average TPLS) [30].
Numerous methodological studies have shown the
reference range values and good feasibility and reproducibility of the application of speckle tracking technique
to measure LA myocardial longitudinal deformation
(Table 2) [22-25]. Regarding the measurement of peak
atrial strain, as stated in the current ASE/EAE Consensus [31], two techniques have been proposed to quantify
atrial deformation by STE, which differ only by the
choice of frame from which start processing software.
The first takes as reference point the QRS onset and
measures the positive peak atrial longitudinal strain, corresponding to atrial reservoir, the second uses the P
wave as the reference point, enabling the measurement
of a first negative peak atrial longitudinal strain, corresponding to atrial systole, a second positive peak atrial
strain, corresponding to LA conduit function, and their
sum.
Advantages and Limitations

STE analysis allows an excellent assessment of atrial

deformation profile during an entire cardiac cycle, closely following LA physiology [22]. Considering the limitations of classical indices of LA function, assessment
of LA strain by speckle tracking may represent a relatively rapid and easy-to-perform technique to explore
LA function, due to its semi-automated nature and to
its off-line processing. In fact, in contrast to Dopplerderived parameters, speckle tracking has the advantage
of being angle-independent, and to be less affected by
reverberations, side lobes and drop out artefacts [22].
Nonetheless, intrinsic limitations of speckle tracking
include strict frame rate dependency, potential errors in
epicardial/endocardial border tracing in subjects with
suboptimal image quality, and need for an appropriate
learning curve to achieve adequate experience in using
analysis software. In fact, the potential difficulty of accurately obtaining a region of interest close enough to the
Table 2 Reference values of global, 4-chamber, and
2-chamber peak atrial longitudinal strain (PALS) and
time to peak strain (TPLS).
Mean DS

5-95 Percentile

PALS (%)
Global

42.2 6.1

32.2 - 53.2

4-chamber

40.1 7.9

29.0 - 53.6

2-chamber

44.3 6.0

35.2 - 52.7

Global

368.0 29.9

322.9 - 430.4

4-chamber

364.2 42.6

300.8 - 436.9

2-chamber

367.4 34.1

326.4 - 435.2

TPLS (ms)

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effective shape of the left atrium, and the risk of contamination by signal components arising from structures
surrounding the left atrium should be considered [22].
Lastly, because a dedicated software for LA strain analysis has not yet been released, the analysis is performed
using a software created for the left ventricle; for this
reason, it is mandatory to be careful in the endocardial
border delineation, excluding from the analysis the auricola and the outlet of the pulmonary veins, in order to
minimize the risk of artefacts caused by signals from
these structures [4].
Clinical applications

The LA mechanical function studied by STE can be

described by three phases, in which the atrial strain curve
closely follow LV dynamics during the cardiac cycle [22].
In fact during the period of LA reservoir, corresponding
to the phases of LV isovolumic contraction, ejection, and
isovolumic relaxation, LA strain increases, achieving a
peak at the end of LA filling, due to the downward movement of the mitral annulus towards the apex, as a result
of LV contraction. In the same way, during the conduit
and LA contraction phases, the LA strain curve reflects
inversely the pattern of LV myocardial deformation.
Therefore LA function seems to be influenced not only
by LA stiffness but also by LV compliance during ventricular filling and by contraction through the descent of
the base during LV systole [32].
It has been recently demonstrated that this new
approach for the study of LA function is of potential clinical importance in a number of pathophysiologic conditions typically associated to abnormal LA function, e.g.
mitral valve diseases, supraventricular arrhythmias, systemic hypertension, ischemic heart disease, heart failure,
atrial stunning, and cardiomyopathies [22].
In this overview, we have decided to focus on two of
these pathologic conditions in which atrial strain imaging may be helpful in clinical management of patients.
Diastolic Function

Patients with diastolic heart failure (DHF) suffer from

increased morbidity and mortality. Although advanced
age, hypertension, diabetes, coronary heart disease and
female gender identify patients at high risk of DHF, the
underlying pathophysiological mechanisms for the transition from an asymptomatic state to a state of symptomatic heart failure are not well defined [33,34].
A study performed by measuring the Doppler strain
rate atrial performance revealed that a reduction of
atrial strain rate is able, in contrast to the atrial ventricular mass and volume, to differentiate patients with
DHF than patients with simple diastolic dysfunction
[35]. Using STE, it has been demonstrated in hypertensive patients, diabetic and hypertensive-diabetic
patients with ejection fraction and LA volumes

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preserved, that the atrial strain occurs progressively

reduced, demonstrating the ability of this new method
in identifying the premature atrial dysfunction before
the appearance of LA structural changes, identified also
by standard methods (atrial dilatation) (Figure 5) [36].
In addition, a study in hypertensive patients at an early
stage, with no evidence of increased ventricular mass,
showed early alterations of atrial strain even before the
development of diastolic dysfunction [37]. Even in athletes it has been recently shown a particular LA strain
pattern [38].
The analysis of atrial strain has resulted very useful also
to other clinical settings, as in end-stage heart failure. In
these patients it is essential the management of the precarious hemodynamic balance and the accurate estimation of
left ventricular filling pressure is very useful to assure

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proper management. The ratio E/E, the main parameter

for echocardiographic estimation of ventricular filling
pressures, was recently proved inadequate for this purpose
[39]. Atrial longitudinal strain has instead demonstrated a
good correlation and diagnostic performance in an accurate estimation of high pulmonary capillary wedge pressure (> 18 mmHg) [40,41]; greater left ventricular filling
pressure is associated to a reduced left atrial deformation.
Atrial Fibrillation

From the pathophysiological point of view this arrhythmia is related to the remodelling and atrial dilatation,
as determined by the proliferation and differentiation
of fibroblasts into myofibroblasts and by the increase
of connective tissue resulting in the appearance of
fibrosis. This structural remodelling determines dissociation between muscle bundles and electrical

Figure 5 Peak atrial longitudinal strain measurements in a healthy subject (A) and in a hypertensive (B), diabetic (C) and
hypertensive-diabetic (D) patients. Atrial strain appeared reduced in hypertensive and in diabetics. In the case of association of the two
diseases the reduction is even more evident.

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alterations in the conduction of electrical stimulation,

which would facilitate the initiation and maintenance
of this arrhythmia. For this reason it is very useful to
analyze the alterations in the function of the left atrium
that can potentially help us in the study of this rhythm
disorder. In patients with chronic AF often dysfunction
and dilatation of the left atrium are present. Through
the analysis of strain of the LA, it appears that the
peak strain of atrial contraction is absent (Figure 6);
recent evidences have demonstrated that lower PALS
correlated with cerebral stroke events [42,43]; PALS is
reduced after electrical cardioversion or ablation of the
sinus node, while it increases gradually in subsequent
months (Figure 7). Several studies have shown that the
strain rate curve of the left atrium is impaired in
patients with AF. The peak systolic strain rate is
reduced in patients with paroxysms of AF and chronic
AF in particular, goes gradually to normalization after
cardioversion [44], and is inversely related to age, LA
volume [45,46], and the presence of LA wall fibrosis
[47]. Even the peak of atrial contraction is reduced
[48], and this value is inversely correlated with pulmonary pressures. In patients with various degrees of
mitral regurgitation it has been demonstrated, in addition to a progressively reduced atrial strain (Figure 8)
[30], that subjects with the same severity of valvular
disease, atrial strain was significantly lower in patients
who reported a history of episodes of paroxysmal atrial
fibrillation (Figure 9) [49].

Discussion
LA size and function data may fulfil the gaps left by the
other conventional two-dimensional echocardiographic
parameters and may allow a more complete diagnosis
characterization. In fact, the evaluation of the left atrium
has been until recently performed by echocardiographic
purely with morphometric and static parameters, such
as the anterior-posterior diameter, area and 2D volume.

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However, the property role of the left atrium is very

important in maintaining cardiac performance [50].
Actually, real-time 3-dimensional echocardiography
permits to assess the physiologic volume changes of the
left atrium during cardiac cycle and to quantify the contribution of LA contraction to LV filling, through the
measurement of LAEF [16].
While LA size provides information of long-term
hemodynamic control, the study of atrial myocardial
deformation by STE is able to improve our understanding on LA function. In fact STE allows noninvasive
assessment of global LA function and regional deformation of LA walls; two-dimensional strain imaging also
successfully provides LA volume curves during one cardiac cycle, from which various LA mechanical indices
can be obtained and allows a direct assessment of LA
contractility and passive deformation.
Several studies have shown that strain imaging can
detect LA dysfunction before the manifestation of LA
structural changes. The decrease of LA reservoir and the
increase of LA pump functions are the first manifestations of the burden of diastolic dysfunction, appearing
before the LA structural changes [51].
Considering the limitations of classical indices of LA,
3D volume and speckle strain assessment of LA may
represent a relatively rapid and easy-to-perform technique to explore LA size and function.

Conclusion
LA size and function carry important clinical and prognosis implications.
The measurement of LA volume by 3D echocardiography is superior to the other conventional 2D parameters
as a measure of LA size and should be incorporate into
routine clinical evaluation. Regional assessment of LA
function by STE also provides more detailed information
about LA mechanics and may prove to have a very
important clinical impact.

Figure 6 Comparison of peak atrial longitudinal strain in a healthy subject (left) and one patient with atrial fibrillation (right). Note in
the patient with atrial fibrillation the disappearance of the second deflection of the curve, relative to the atrial contraction phase.

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Figure 7 Evaluation of left atrial strain and strain rate before and after electrical cardioversion. Note the progressive improvement of the
peak strain and the reappearance of the second deflection of the atrial strain curve, relative to the atrial contraction phase.

Figure 8 Peak Atrial Longitudinal Strain (PALS): two representative cases of an healthy control (left) and of a patient with severe
mitral regurgitation (right).

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Figure 9 Relation of global peak atrial longitudinal strain (PALS) to the presence or absence of paroxysmal atrial fibrillation (PAF)
episodes, cross-tabulated by category of each underlying mitral regurgitation severity.

Authors contributions
MC conceived the review and drafted the manuscript. ML revised critically
the manuscript and added figures which resulted in a more readable
manuscript and finally helped in the collection of the bibliography
suggesting some important papers reported in the review and improved
the chapter concerning three-dimensional echocardiography. FMR
suggested the scheme of the review and revised critically the paper,
contributed and improved the chapters concerning the role of the new
technology of speckle tracking echocardiography. SM participated in the
design of the review and gave the final approval. All authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 23 July 2011 Accepted: 1 February 2012
Published: 1 February 2012
References
1. Phang RS, Isserman SM, Karia D, Pandian NG, Homoud MS, Link MS,
Estes NA, Wang PJ: Echocardiographic evidence of left atrial abnormality
in young patients with lone paroxysmal atrial fibrillation. Am J Cardiol
2004, 94:511-3.
2. Moller JE, Hillis GS, Oh JK, Seward JB, Reeder GS, Wright RS, Park SW,
Bailey KR, Pellikka PA: Left atrial volume: a powerful predictor of survival
after acute myocardial infarction. Circulation 2003, 107:2207-12.
3. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB: Left atrial volume as a
morphophysiologic expression of left ventricular diastolic dysfunction
and relation to cardiovascular risk burden. Am J Cardiol 2002, 90:1284-9.
4. Mondillo S, Galderisi M, Mele D, Cameli M, Lomoriello VS, Zac V, Ballo P,
DAndrea A, Muraru D, Losi M, Agricola E, DErrico A, Buralli S, Sciomer S,
Nistri S, Badano L: Echocardiography Study Group Of The Italian Society
Of Cardiology (Rome, Italy). Speckle-tracking echocardiography: a new
technique for assessing myocardial function. J Ultrasound Med 2011,
30(1):71-83.

5.

6.

7.

8.

9.

10.

11.

12.

13.

Tsang TS, Barnes ME, Bailey KR, Leibson CL, Montgomery SC, Takemoto Y,
Diamond PM, Marra MA, Gersh BJ, Wiebers DO, Petty GW, Seward JB: Left
atrial volume: important risk marker of incident aial fibrillation in 1655
older men and women. Mayo Clin Proc 2001, 76:467-75.
Barnes ME, Miyasaka Y, Seward JB, Gersh BJ, Rosales AG, Bailey KR,
Petty GW, Wiebers DO, Tsang TS: Left atrial volume in the prediction of
first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo
Clin Proc 2004, 79:1008-14.
Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR,
Cha SS, Seward JB: Prediction of cardiovascular outcomes with left atrial
size: is volume superior to area or diameter? J Am Coll Cardiol 2006,
47:1018-23.
Lang RM, Bierig M, Devereux RB, Lang RM, Flachskampf FA, Foster E,
Pellika PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S,
Spencer KT, St John Sutton M, Stewart W: Recommendations for chamber
quantification. Eur J Echocardiography 2006, 7:79-108.
Anwar AM, Soliman OI, Geleijnse ML, Nemes A, Vletter WB, tenCate FJ:
Assessment of left atrial volume and function by real-time threedimensional echocardiography. Int J Cardiol 2008, 123:155-61.
Miyasaka Y, Tsujimoto S, Maeba H, Yuasa F, Takehana K, Dote K, Iwasaka T:
Left atrial volume by three-dimensional echocardiography: validation by
64-slice multidetector computed tomography. J Am Soc Echocardiogr
2011, 24:680-6.
Aune E, Baekkevar M, Roislien J, Rodevand O, Otterstad JE: Normal
reference range for left and right atrial volume indexes and ejection
fractions obtained with real-time three-dimensional echocardiography.
Eur J Echocardiogr 2009, 10:738-44.
Rodevan O, Bjornerheim R, Ljosland M, Maehle J, Smith HJ, Ihlen H: Left
atrial volumes assessed by three- and two-dimensional
echocardiography compared to MRI estimates. Int J Card Imaging 1999,
15:397-410.
Artang R, Migrino RQ, Harmann L, Bowers M, Woods TD: Left atrial volume
measurement with automated border detection by 3-dimensional
echocardiography: comparison with magnetic resonance imaging.
Cardiovasc Ultrasound 2009, 7:16-24.

Cameli et al. Cardiovascular Ultrasound 2012, 10:4

http://www.cardiovascularultrasound.com/content/10/1/4

14. Keller AM, Gopal AS, King DL: Left and right atrial volume by freehand
three-dimensional echocardiography: in vivo validation using magnetic
resonance imaging. Eur J Echocardiogr 2000, 1:55-65.
15. Khankirawatana B, Khankirawatana S, Lof J, Porter TR: Left atrial volume
determination by three-dimensional echocardiography reconstruction:
validation and application of a simplied technique. J Am Soc Echocardiogr
2002, 15:1051-6.
16. Murata M, Iwanaga S, Tamura Y, Kondo M, Kouyama K, Murata M, Ogawa S:
Real-time three-dimensional echocardiographic quantitative analysis of
left ventricular diastolic dysfunction. Am J Cardiol 2008, 8:1097-102.
17. Maddukuri PV, Vieira MCL, De castro S, Maron MS, Kuvin JT, Patel AR,
Pandian NG: What is the best approach for the assessment of left atrial
size? Comparison of various unidimensional and two-dimensional
parameters with three-dimensional echocardiographically determined
left atrial volume. J Am Soc Echocardiogr 2006, 19:1026-32.
18. Jenkins C, Chan J, Hanekom L, Marwick TH: Accuracy and feasibility of
online 3-dimensional echocardiography for measurement of left
ventricular parameters. J Am Soc Echocardiogr 2006, 19:1119-28.
19. Hung J, Lang R, Flachskampf F, Shernan S, McCulloch ML, Adams DB,
Thomas J, Vannan M, Ryan T: 3D echocardiography: a review of the current
status and future directions. J Am Soc Echocardiogr 2007, 20:213-233.
20. Abhayaratna WP, Seward J, Appleton CP, Douglas PS, Oh JK, Tajik AJ,
Tsang TSM: Left atrial size. Physiologic determinants and clinical
applications. J Am Coll Cardiol 2006, 47:2357-63.
21. Suh IW, Song JM, Lee EY, Kang SH, Kim MJ, Kim JJ, Kang DH, Song JK: Left
atrial volume measured by real-time 3 dimensional echocardiography
predicts clinical outcomes in patients with severe left ventricular
dysfunction and in sinus rhythm. J Am Soc Echocardiogr 2008:439-445.
22. Cameli M, Caputo M, Mondillo S, Ballo P, Palmerini E, Lisi M, Marino E,
Galderisi M: Feasibility and reference values of left atrial longitudinal
strain imaging by two-dimensional speckle tracking. Cardiovascular
Ultrasound 2009, 7:6.
23. Vianna-Pinton R, Moreno CA, Baxter CM, Lee KS, Tsang TS, Appleton CP:
Two-Dimensional Speckle-Tracking Echocardiography of the Left Atrium:
Feasibility and Regional Contraction and Relaxation Differences in
Normal Subjects. J Am Soc Echocardiogr 2009, 22:299-305.
24. Kim DG, Lee KJ, Lee S, Jeong SY, Lee YS, Choi YJ, Yoon HS, Kim JH,
Jeong KT, Park SC, Park M: Feasibility of two-dimensional global
longitudinal strain and strain rate imaging for the assessment of left
atrial function: a study in subjects with a low probability of
cardiovascular disease and normal exercise capacity. Echocardiography
2009, 26:1179-87.
25. Saraiva RM, Demirkol S, Buakhamsri A, Greenberg N, Popovi ZB,
Thomas JD, Klein AL: Left atrial strain measured by two-dimensional
speckle tracking represents a new tool to evaluate left atrial function. J
Am Soc Echocardiogr 2010, 23:172-80.
26. Sirbu C, Herbots L, Dhooge J, Claus P, Marciniak A, Langeland T, Bijnens B,
Rademakers FE, Sutherland GR: Feasibility of strain and strain rate
imaging for the assessment of regional left atrial deformation: a study
in normal subjects. Eur J Echocardiogr 2006, 7:199-208.
27. Okamatsu K, Takeuchi M, Nakai H, Nishikage T, Salgo IS, Husson S, Otsuji Y,
Lang RM: Effects of aging on left atrial function assessed by twodimensional speckle tracking echocardiography. J Am Soc Echocardiogr
2009, 22:70-75.
28. DAndrea A, Caso P, Romano S, Scarafile R, Riegler L, Salerno G,
Limongelli G, Di Salvo G, Calabr P, Del Viscovo L, Romano G, Maiello C,
Santangelo L, Severino S, Cuomo S, Cotrufo M, Calabr R: Different effects
of cardiac resynchronization therapy on left atrial function in patients
with either idiopathic or ischaemic dilated cardiomyopathy: a twodimesnsional spekle strain study. Eur Heart J 2007, 28:2738-2748.
29. Di Salvo G, Pacileo G, Castaldi B, Gala S, Morelli C, DAndrea A, Limongelli G,
Del Gaizo F, Merlino E, Russo MG, Calabr R: Two-dimensional strain and
atrial function: a study on patients after percutaneous closure of atrial
septal defect. Eur J Echocardiogr 2009, 10:256-259.
30. Cameli M, Lisi M, Giacomin E, Caputo M, Navarri R, Malandrino A, Ballo P,
Agricola E, Mondillo S: Chronic Mitral Regurgitation: Left Atrial
Deformation Analysis by Two-Dimensional Speckle Tracking
Echocardiography. Echocardiography 2011, 28(3):327-34.
31. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G,
Galderisi M, Marwick T, Nagueh SF, Sengupta PP, Sicari R, Smiseth OA,
Smulevitz B, Takeuchi M, Thomas JD, Vannan M, Voigt JU, Zamorano JL:

Page 12 of 13

32.

33.

34.

35.
36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

Current and Evolving Echocardiographic Techniques for the Quantitative

Evaluation of Cardiac Mechanics: ASE/EAE Consensus Statement on
Methodology and Indications Endorsed by the Japanese Society of
Echocardiography. Eur J Echocardiogr 2011, 12(3):167-205.
Barbier P, Solomon SB, Shiller NB, Glantz SA: Left atrial relaxation and left
ventricular systolic function determine left atrial reservoir function.
Circulation 1999, 100:427-436.
Melenovsky V, Borlaug BA, Rosen B, Hay I, Ferruci L, Morell CH, Lakatta EG,
Najjar SS, Kass DA: Cardiovascular features of heart failure with preserved
ejection fraction versus nonfailing hypertensive left ventricular
hypertrophy in the urban Baltimore community: the role of atrial
remodeling/dysfunction. J Am Coll Cardiol 2007, 49:198-207.
Gottdiener JS, Kitzman DW, Aurigemma GP, Arnold AM, Manolio TA: Left
atrial volume, geometry, and function in systolic and diastolic heart
failure of persons > or = 65 years of age (The cardiovascular health
study). Am J Cardiol 2006, 97:83-89.
Kurt M, Wang J, Torre-Amione G, Nagueh SF: Left atrial function in
diastolic heart failure. Circ Cardiovasc Imaging 2009, 2:10-15.
Mondillo S, Cameli M, Caputo ML, Lisi M, Palmerini E, Padeletti M, Ballo P:
Early Detection of Left Atrial Strain Abnormalities by Speckle-Tracking in
Hypertensive and Diabetic Patients with Normal Left Atrial Size. J Am
Soc Echocardiogr 2011, 24:898-908.
Cameli M, Lisi M, Righini F, Ballo P, Henein M, Mondillo S: Early detection
of left atrial dysfunction in patients with hypertension by twodimensional speckle tracking echocardiography. (abstr)In: EUROECHO
Congress. Copenaghen 2010. Eur J Echocardiogr, Abstracts Supplement
2010, P802.
DAscenzi F, Cameli M, Zac V, Lisi M, Santoro A, Causarano A, Mondillo S:
Supernormal diastolic function and role of left atrial myocardial
deformation analysis by 2D speckle tracking echocardiography in elite
soccer players. Echocardiography 2011, 28(3):320-6.
Mullens W, Borowski A, Curtin R, Thomas J, Tang W: Tissue Doppler
imaging in the estimation of intracrdiac filling pressure in
decompensated patients with advanced systolic heart failure. Circulation
2009, 119:62-70.
Wakami K, Ohte N, Asada K, Fukuta H, Goto T, Mukai S, Narita H, Kimura G:
Correlation between left ventricular end-diastolic pressure and peak left
atrial wall strain during left ventricular systole. J Am Soc Echocardiogr
2009, 22:847-851.
Cameli M, Lisi M, Mondillo S, Padeletti M, Ballo P, Tsioulpas C, Bernazzali S,
Maccherini M: Left atrial longitudinal strain by speckle tracking
echocardiography correlates well with left ventricular filling pressures in
patients with heart failure. Cardiovasc Ultrasound 2010, 8:14.
Shih JY, Tsai WC, Huang YY, Liu YW, Lin CC, Huang YS, Tsai LM, Lin LJ:
Association of decreased left atrial strain and strain rate with stroke in
chronic atrial fibrillation. J Am Soc Echocardiogr 2011, 24(5):513-9.
Saha SK, Anderson PL, Caracciolo G, Kiotsekoglou A, Wilansky S, Govind S,
Mori N, Sengupta PP: Global Left Atrial Strain Correlates with CHADS(2)
Risk Score in Patients with Atrial Fibrillation. J Am Soc Echocardiogr 2011,
24(5):506-12.
Donal E, Ollivier R, Veillard D, Hamonic S, Pavin D, Daubert JC, Mabo P: Left
atrial function assessed by trans-thoracic echocardiography in patients
treated by ablation for a lone paroxysmal atrial fibrillation. Eur J
Echocardiogr 2010, 11:845-52.
Inaba Y, Yuda S, Kobayashi N, Hashimoto A, Uno K, Nakata T, Tsuchihashi K,
Miura T, Ura N, Shimamoto K: Strain rate imaging for noninvasive
functional quantification of the left atrium: comparative studies in
controls and patients with atrial fibrillation. J Am Soc Echocardiogr 2005,
18:729-736.
Schneider C, Malisius R, Krause K, Lampe F, Bahlmann E, Boczor S, Antz M,
Ernst S, Kuck KH: Strain rate imaging for functional quantification of the
left atrium: atrial deformation predicts the maintenance of sinus rhythm
after catheter ablation of atrial fibrillation. European Heart Journal 2008,
29:1397-1409.
Kuppahally SS, Akoum N, Burgon NS, Badger TJ, Kholmovski EG,
Vijayakumar S, Rao SN, Blauer J, Fish EN, Dibella EV, Macleod RS, McGann C,
Litwin SE, Marrouche NF: Left atrial strain and strain rate in patients with
paroxysmal and persistent atrial fibrillation: relationship to left atrial
structural remodeling detected by delayed-enhancement MRI. Circ
Cardiovasc Imaging 2010, 3(3):231-9.

Cameli et al. Cardiovascular Ultrasound 2012, 10:4

http://www.cardiovascularultrasound.com/content/10/1/4

Page 13 of 13

48. Tsai WC, Lee CH, Lin CC, Liu YW, Huang YY, Li WT, Chen JY, Lin LJ:
Association of left atrial strain and strain rate assessed by speckle
tracking echocardiography with paroxysmal atrial fibrillation.
Echocardiography 2009, 26:10.
49. Cameli M, Lisi M, Righini FM, Focardi M, Alfieri O, Mondillo S: Left atrial
speckle tracking analysis in patients with mitral insufficiency and history
of paroxysmal atrial fibrillation. Int J Cardiovasc Imaging 2011.
50. Leung DY, Boyd A, Ng AA, Chi C, Thomas L: Echocardiographic evaluation
of left atrial size and function: Current understanding, pathophysiologic
correlates, and prognostic implications. Am Heart J 2008, 156:1056-64.
51. Kokubu N, Yuda S, Tsuchihashi K, Hashimoto A, Nakata T, Miura T, Ura N,
Nagao K, Tsuzuki M, Wakabayashi C, Shimamoto K: Noninvasive
assessment of left atrial function by strain rate imaging in patients with
hypertension: a possible benificial effect of Renin-Angiotensin System
Inhibition on left atrial function. Hypertens Res 2007, 30:13-21.
doi:10.1186/1476-7120-10-4
Cite this article as: Cameli et al.: Novel echocardiographic techniques to
assess left atrial size, anatomy and function. Cardiovascular Ultrasound
2012 10:4.

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