Echocardiographic evaluation of the atria and appendages
- Elyse Foster, MD
Elyse Foster, MD
- Professor of Clinical Medicine
- University of California, San Francisco
Imaging of the right and left atria and their appendages can provide important diagnostic and prognostic information. Left atrial imaging is especially important in patients with atrial fibrillation who are at increased risk for thromboembolic events resulting from left atrial or atrial appendage thrombus. Imaging of the left atrium has gained increased importance in association with new investigational procedures for atrial appendage occlusion in patients with atrial fibrillation used for stroke prophylaxis.
This topic will review the echocardiographic evaluation of the right and left atria and their appendages. The role of echocardiography in atrial fibrillation is discussed in detail elsewhere. (See "Role of echocardiography in atrial fibrillation".)
The left atrium can be easily imaged in a number of views by transthoracic (surface) or transesophageal echocardiography. In addition to being a site of thrombosis in atrial fibrillation, the left atrium can be involved in a number of disease processes:
●It commonly dilates with age through a process that seems to be linked to "senile" left ventricular diastolic dysfunction and other diseases affecting the left ventricle such as hypertrophic, dilated, or restrictive cardiomyopathy.
●Left atrial dilation occurs in association with chronic atrial fibrillation, Dilation can promote atrial fibrillation by perturbing propagation of orderly depolarization . Conversely, permanent atrial fibrillation can promote LA dilation. (See "Mechanisms of atrial fibrillation".)
- Goldman JH, Ehlgen A, Ursell PC, Schiller NB. Left atrial size is a poor predictor of pathology in the older patient: preliminary observations. Echocardiography 2006; 23:24.
- Pelliccia A, Maron BJ, Di Paolo FM, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 2005; 46:690.
- Vered Z, Poler SM, Gibson P, et al. Noninvasive detection of the morphologic and hemodynamic changes during normal pregnancy. Clin Cardiol 1991; 14:327.
- Iwasaki T, Naka M, Hiramatsu K, et al. Echocardiographic studies on the relationship between atrial fibrillation and atrial enlargement in patients with hyperthyroidism of Graves' disease. Cardiology 1989; 76:10.
- Silvestre OM, Bacal F, de Souza Ramos D, et al. Impact of the severity of end-stage liver disease in cardiac structure and function. Ann Hepatol 2013; 12:85.
- Schabelman S, Schiller NB, Silverman NH, Ports TA. Left atrial volume estimation by two-dimensional echocardiography. Cathet Cardiovasc Diagn 1981; 7:165.
- Lester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical practice and in research studies to determine left atrial size. Am J Cardiol 1999; 84:829.
- Nakai T, Lee RJ, Schiller NB, et al. The relative importance of left atrial function versus dimension in predicting atrial fibrillation after coronary artery bypass graft surgery. Am Heart J 2002; 143:181.
- Block M, Hourigan L, Bellows WH, et al. Comparison of left atrial dimensions by transesophageal and transthoracic echocardiography. J Am Soc Echocardiogr 2002; 15:143.
- Kircher B, Abbott JA, Pau S, et al. Left atrial volume determination by biplane two-dimensional echocardiography: validation by cine computed tomography. Am Heart J 1991; 121:864.
- Koka AR, Gould SD, Owen AN, Halpern EJ. Left atrial volume: comparison of 2D and 3D transthoracic echocardiography with ECG-gated CT angiography. Acad Radiol 2012; 19:62.
- Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440.
- Thomas L, Levett K, Boyd A, et al. Compensatory changes in atrial volumes with normal aging: is atrial enlargement inevitable? J Am Coll Cardiol 2002; 40:1630.
- Thomas L, Levett K, Boyd A, et al. Changes in regional left atrial function with aging: evaluation by Doppler tissue imaging. Eur J Echocardiogr 2003; 4:92.
- Thomas L, Thomas SP, Hoy M, et al. Comparison of left atrial volume and function after linear ablation and after cardioversion for chronic atrial fibrillation. Am J Cardiol 2004; 93:165.
- Thomas L, Boyd A, Thomas SP, et al. Atrial structural remodelling and restoration of atrial contraction after linear ablation for atrial fibrillation. Eur Heart J 2003; 24:1942.
- Blume GG, Mcleod CJ, Barnes ME, et al. Left atrial function: physiology, assessment, and clinical implications. Eur J Echocardiogr 2011; 12:421.
- Pritchett AM, Jacobsen SJ, Mahoney DW, et al. Left atrial volume as an index of left atrial size: a population-based study. J Am Coll Cardiol 2003; 41:1036.
- Ristow B, Ali S, Whooley MA, Schiller NB. Usefulness of left atrial volume index to predict heart failure hospitalization and mortality in ambulatory patients with coronary heart disease and comparison to left ventricular ejection fraction (from the Heart and Soul Study). Am J Cardiol 2008; 102:70.
- Di Tullio MR, Sacco RL, Sciacca RR, Homma S. Left atrial size and the risk of ischemic stroke in an ethnically mixed population. Stroke 1999; 30:2019.
- Moller JE, Hillis GS, Oh JK, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation 2003; 107:2207.
- Sakaguchi E, Yamada A, Sugimoto K, et al. Prognostic value of left atrial volume index in patents with first acute myocardial infarction. Eur J Echocardiogr 2011; 12:440.
- Zile MR, Gottdiener JS, Hetzel SJ, et al. Prevalence and significance of alterations in cardiac structure and function in patients with heart failure and a preserved ejection fraction. Circulation 2011; 124:2491.
- Leung DY, Chi C, Allman C, et al. Prognostic implications of left atrial volume index in patients in sinus rhythm. Am J Cardiol 2010; 105:1635.
- Kou S, Caballero L, Dulgheru R, et al. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study. Eur Heart J Cardiovasc Imaging 2014; 15:680.
- Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1.
- Manning WJ, Weintraub RM, Waksmonski CA, et al. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med 1995; 123:817.
- Hwang JJ, Chen JJ, Lin SC, et al. Diagnostic accuracy of transesophageal echocardiography for detecting left atrial thrombi in patients with rheumatic heart disease having undergone mitral valve operations. Am J Cardiol 1993; 72:677.
- Providência R, Trigo J, Paiva L, Barra S. The role of echocardiography in thromboembolic risk assessment of patients with nonvalvular atrial fibrillation. J Am Soc Echocardiogr 2013; 26:801.
- Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991; 17:66.
- Sallach JA, Puwanant S, Drinko JK, et al. Comprehensive left atrial appendage optimization of thrombus using surface echocardiography: the CLOTS multicenter pilot trial. J Am Soc Echocardiogr 2009; 22:1165.
- Manning WJ, Silverman DI, Keighley CS, et al. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol 1995; 25:1354.
- Weigner MJ, Thomas LR, Patel U, et al. Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: short-term safety and impact on maintenance of sinus rhythm at 1 year. Am J Med 2001; 110:694.
- Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001; 344:1411.
- Srimannarayana J, Varma RS, Satheesh S, et al. Prevalence of left atrial thrombus in rheumatic mitral stenosis with atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study. Indian Heart J 2003; 55:358.
- Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med 1998; 128:639.
- Manning WJ, Silverman DI, Waksmonski CA, et al. Prevalence of residual left atrial thrombi among patients with acute thromboembolism and newly recognized atrial fibrillation. Arch Intern Med 1995; 155:2193.
- Agmon Y, Khandheria BK, Gentile F, Seward JB. Clinical and echocardiographic characteristics of patients with left atrial thrombus and sinus rhythm: experience in 20 643 consecutive transesophageal echocardiographic examinations. Circulation 2002; 105:27.
- Agmon Y, Khandheria BK, Gentile F, Seward JB. Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 1999; 34:1867.
- Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. Heart 1999; 82:547.
- Bernier M, Abdelmoneim SS, Stuart Moir W, et al. CUTE-CV: a prospective study of enhanced left atrial appendage visualization with microbubble contrast agent use during transesophageal echocardiography guided cardioversion. Echocardiography 2013; 30:1091.
- Bartus K, Han FT, Bednarek J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol 2013; 62:108.
- Freixa X, Tzikas A, Sobrino A, et al. Left atrial appendage closure with the Amplatzer™ Cardiac Plug: impact of shape and device sizing on follow-up leaks. Int J Cardiol 2013; 168:1023.
- Bayard YL, Omran H, Neuzil P, et al. PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) for prevention of cardioembolic stroke in non-anticoagulation eligible atrial fibrillation patients: results from the European PLAATO study. EuroIntervention 2010; 6:220.
- Mügge A, Kühn H, Nikutta P, et al. Assessment of left atrial appendage function by biplane transesophageal echocardiography in patients with nonrheumatic atrial fibrillation: identification of a subgroup of patients at increased embolic risk. J Am Coll Cardiol 1994; 23:599.
- Jue J, Winslow T, Fazio G, et al. Pulsed Doppler characterization of left atrial appendage flow. J Am Soc Echocardiogr 1993; 6:237.
- Agmon Y, Khandheria BK, Meissner I, et al. Left atrial appendage flow velocities in subjects with normal left ventricular function. Am J Cardiol 2000; 86:769.
- Pálinkás A, Antonielli E, Picano E, et al. Clinical value of left atrial appendage flow velocity for predicting of cardioversion success in patients with non-valvular atrial fibrillation. Eur Heart J 2001; 22:2201.
- Antonielli E, Pizzuti A, Pálinkás A, et al. Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation. J Am Coll Cardiol 2002; 39:1443.
- Quraini D, Pandian NG, Patel AR. Three-dimensional echocardiographic analysis of right atrial volume in normal and abnormal hearts: comparison of biplane and multiplane methods. Echocardiography 2012; 29:608.
- Yavuz T, Nazli C, Kinay O, Kutsal A. Giant eustachian valve with echocardiographic appearance of divided right atrium. Tex Heart Inst J 2002; 29:336.
- Sawhney N, Palakodeti V, Raisinghani A, et al. Eustachian valve endocarditis: a case series and analysis of the literature. J Am Soc Echocardiogr 2001; 14:1139.
- Vale TA, Newton JD, Orchard E, et al. Prominence of the Eustachian valve in paradoxical embolism. Eur J Echocardiogr 2011; 12:33.
- Goel SS, Tuzcu EM, Shishehbor MH, et al. Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. Am J Cardiol 2009; 103:124.
- de Divitiis M, Omran H, Rabahieh R, et al. Right atrial appendage thrombosis in atrial fibrillation: its frequency and its clinical predictors. Am J Cardiol 1999; 84:1023.
- Rostagno C, Olivo G, Comeglio M, et al. Left atrial size changes in patients with paroxysmal lone atrial fibrillation. An echocardiographic follow-up. Angiology 1996; 47:797.
- Reeder GS, Khandheria BK, Seward JB, Tajik AJ. Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 1991; 66:1101.
- Mügge A, Daniel WG, Haverich A, Lichtlen PR. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches. Circulation 1991; 83:70.
- Alam M, Sun I, Smith S. Transesophageal echocardiographic evaluation of right atrial mass lesions. J Am Soc Echocardiogr 1991; 4:331.
- Allen G, Klingman R, Ferraris VA, et al. Transesophageal echocardiography in the surgical management of renal cell carcinoma with intracardiac extension. J Cardiovasc Surg (Torino) 1991; 32:833.
- Hasnain JU, Watson RJ. Transesophageal echocardiography during resection of renal cell carcinoma involving the inferior vena cava. South Med J 1994; 87:273.
- Treiger BF, Humphrey LS, Peterson CV Jr, et al. Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension. J Urol 1991; 145:1138.
- Van Camp G, Abdulsater J, Cosyns B, et al. Transesophageal echocardiography of right atrial metastasis of a hepatocellular carcinoma. Chest 1994; 105:945.
- Simonson JS, Schiller NB. Sonospirometry: a new method for noninvasive estimation of mean right atrial pressure based on two-dimensional echographic measurements of the inferior vena cava during measured inspiration. J Am Coll Cardiol 1988; 11:557.
- Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr 2007; 20:857.
- LEFT ATRIUM
- M-mode echocardiogram
- - LA dimension
- Two-dimensional echocardiography
- - LA volume
- - LA thrombus
- Transesophageal echocardiography
- - Detection of thrombi
- - Thrombus in sinus rhythm
- - Left atrial masses and tumors
- LEFT ATRIAL APPENDAGE
- Left atrial appendage function
- RIGHT ATRIUM
- Right atrial thrombus
- Right atrial tumors
- VENA CAVA