Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis

Seth N Meltzer; Prajakta M Phatak; Hooman Fazlalizadeh; Ian Chang; Patrick Bering; Benjamin Kenigsberg; Gaby Weissman; Manish H Shah; Lowell F Satler; Toby Rogers; Roberto M Lang; Federico M Asch; Preetham Kumar; Diego Medvedofsky

doi:10.1016/j.echo.2021.03.008

Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis

J Am Soc Echocardiogr. 2021 Sep;34(9):987-995. doi: 10.1016/j.echo.2021.03.008. Epub 2021 Mar 26.

Affiliations

¹ MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia.
² Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
³ Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
⁴ University of Chicago, Medical Center, Chicago, Illinois.
⁵ MedStar Health Research Institute at MedStar Washington Hospital Center, Washington, District of Columbia.
⁶ MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia. Electronic address: diego.a.medvedofsky@medstar.net.

PMID: 33775733
DOI: 10.1016/j.echo.2021.03.008

Abstract

Background: Left atrial appendage (LAA) echocardiographic assessment is difficult because of the complex shape and relatively small size of the LAA. Three-dimensional (3D) echocardiographic imaging can overcome the limitations of two-dimensional imaging. Pulsed-wave Doppler is the only currently standard LAA functional parameter. The aim of this study was to test a new approach for 3D echocardiographic volumetric analysis to obtain LAA ejection fraction (EF), its size and shape.

Methods: Transesophageal two-dimensional and 3D LAA images were prospectively obtained in 159 consecutive patients. LAA volumes were measured from 3D echocardiographic images using available software. Pulsed-wave Doppler was considered the reference value for LAA function and was used for comparison with LAA EF. Comparison with cardiac computed tomography was performed in a subgroup of 32 patients. Comparisons included linear regression and Bland-Altman analyses. Repeated measurements were performed to assess measurement variability.

Results: Nine patients were excluded because of suboptimal image quality (94% feasibility). Three-dimensional LAA calculated EF was in good agreement with LAA pulsed-wave measurements. Three-dimensional morphologic evaluation showed that 43% of the patients had "chicken wing," 33% "cactus," 19% "windsock," and 5% cauliflower shapes. At the time of data acquisition, patients with atrial fibrillation had nonsignificantly larger LAA end-systolic and end-diastolic volumes, leading to lower calculated EFs. Three-dimensional echocardiographic LAA end-systolic volumes were in good agreement with cardiac computed tomography (r = 0.75), with small biases (mean, -2.5 ± 3.9 ml). Reproducibility was better for larger LAA volumes.

Conclusions: A novel 3D echocardiographic approach can determine the geometry, size, and function of the LAA. A new parameter, LAA EF, provides functional quantitation.

Keywords: Atrial fibrillation; Function; Left atrial appendage; Shape; Size; Three-dimensional echocardiography.

MeSH terms

Atrial Appendage* / diagnostic imaging
Atrial Fibrillation* / diagnostic imaging
Echocardiography
Echocardiography, Three-Dimensional*
Echocardiography, Transesophageal
Humans
Reproducibility of Results