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The left atrium in 3D Laura Ernande, MD, PhD Post-doctoral research fellow Harvard medical school Massachusetts General Hospital Boston, USA Learning objectives 1. Left atrial anatomy 1. Assessment of the left atrium by 3D echo 1. Clinical applications Left atrial anatomy Location of the LA • Most posteriorly situated cardiac chamber • More posteriorly and superiorly situated / RA • Neighborhood: • tracheal bifurcation, • esophagus, • and descending thoracic aorta Ho SY, Circ Arrhythm Electrophysiol 2012;5:220-228. Structure of the LA • LA: • begins at the pulmonary veno-atrial junctions • => atrioventricular junction at the mitral orifice. • 3 parts: • Venous component • Vestibule • Appendage (LAA) Ho SY, Circ Arrhythm Electrophysiol 2012;5:220-228. Ho SY, Eur J Echocardiograph 2011;12:i11-i15. LA walls • LA walls are muscular: • • • • • superior posterior left lateral septal (or medial) anterior Ho SY, Circ Arrhythm Electrophysiol 2012;5:220-228. The septal wall • Oblique with the LA more posterior than the RA • Site of the true septum = thin flap valve of the fossa ovalis + muscular rim (limbus) • In 18% of individuals, the rim is flat => no clear distinction between the two structures • On the LA side, the thin fossa valve usually indistinguishable Faletra FF, J Am Soc Echocardiogr 2011;24:593-9. Ho SY, Eur J Echocardiograph 2011;12:i11-i15. The septal wall: anatomic variations • Aneurysmal fossa valve • saccular excursion of > 1 cm away from the plane of the AS • 1/3 of hearts with aneurysmal fossa are associated with a PFO • Patent foramen ovale: 25% adults • Lipomatous hypertrophy of the AS: • Epicardial fat: 1–2 cm in the normal heart • Thickness >2 cm (8%) • Variation of location and size of the FO: If anteriorly situated => close to the aortic root => risk of perforation Kutty S, JACC 2012;59:1665-71. Pulmonary veins • PV enter the posterior part of the LA • Left veins more superior than the right veins • Inferior venous orifices more posterior than the superior • RUPV passes behind the junction between the right atrium and the SCV • RLPV passes behind the intercaval area • Left lateral ridge between the appendage and the left pulmonary veins (can be mistaken for a thrombus or atrial mass) Ho SY, Circ Arrhythm Electrophysiol 2012;5:220-228. Pulmonary veins: anatomic variations • Typical anatomy: - 2 right (82%) and 2 left pulmonary (91%) venous orifices • Common variations: short or long common venous trunk on the left side (8.5%) supernumerary veins on the right side (17%) Thorning C, Clin Imaging. 2011;35:1–9. Left atrial appendage • Finger-like, multilobular extension from the LA body • LAA orifice between the LUPV and the LV • Smaller than the RAA • Externally: multiple crenellations • Endocardial aspect: heavily trabeculated with muscular structures (pectinate muscles) • Close to the circumflex artery Left atrial appendage Sinus rythm • LAA remodeling in patients with AF • Dilation • Reduction in pectinate muscle volume • Endocardial fibroelastosis: endocardial thickening with fibrous and elastic tissue Atrial fibrillation • AF thombi located in the LAA in 90% of the patients Blackshear JL, Ann Thorac Surg 1996; 61:755-9. Shirani J, Cardiovasc Pathol 2000;9:95–101. The vestibule • Outlet part of the atrial chamber surrounding the mitral orifice • Myocardium of its distal parts overlaps the atrial surfaces of the mitral leaflets • Proximal border unclear, especially in the anterior, septal, and inferior portions. Ho SY, Circ Arrhythm Electrophysiol 2012;5:220-228. Assessment of the LA by 3D echo EAE/ASE recommendations 3D imaging of the atrial septum and the fossa ovalis • 2D TEE 90° bicaval plane view • Zoom: • Dimension as large as possible in the x (lateral) and z (elevation) directions, to include the entire IAS and surrounding structures • while the y (depth) direction should be set to include only the left and the right sides of the septum • 90° up-down angulation of the pyramidal data set => En face view of the left side of the septum Lang RM, EAE/ASE recommendations. Eur Heart J CVI 2012;13:1-46. Faletra FF, J Am Soc Echocardiogr 2011;24:593-9. 3D imaging of the atrial septum and the fossa ovalis • Orientation: • RUPV at the one o’clock position • MV left lower corner • 180° counterclockwise rotation => right side of the AS with the fossa ovalis Lang RM, EAE/ASE recommendations Eur Heart J CVI 2012;13:1-46. MV 3D imaging of the atrial septum and the fossa ovalis Right atrial perspective • The fossa ovalis: depression • Gain not too low => Risk of false impression of an ASD Lang RM, EAE/ASE recommendations. Eur Heart J CVI 2012;13:1-46. Faletra FF, J Am Soc Echocardiogr 2011;24:593-9. 3D imaging of the atrial septum and the fossa ovalis Left atrial perspective • IAS appears flat • The fossa ovalis is not recognizable Lang RM, EAE/ASE recommendations. Eur Heart J CVI 2012;13:1-46. Faletra FF, J Am Soc Echocardiogr 2011;24:593-9. Anatomic variability of the fossa ovalis Right atrial perspective • High variability: size, location and shape Faletra FF, J Am Soc Echocardiogr 2011;24:593-9. 3D imaging of the pulmonary veins • Midesophageal 90° TEE view of the mitral valve and LAA • Slight counter clockwise rotation => one or both of the left PV • LLPV more difficult to visualize than the LUPV Lang RM, EAE/ASE recommendations. 2012;13:1-46. 3D imaging of the pulmonary veins • Visualize the AS in “en face” view • From this view the right RV adjacent to the septum Long axis • Crop of the surrounding structures by advancing Yplane box Lang RM, EAE/ASE recommendations. 2012;13:1-46. Short axis 3D imaging of the LAA: multiplane Orthogonal views of the LAA Courtesy of Dr Hélène Thibault 3D imaging of the LAA: longitudinal view View of the LAA in long axis 3D imaging of the LAA: from the LA Zoomed 3D TEE image of the LAA orifice as viewed from the left atrium Courtesy of Dr Marielle Scherrer-Crosbie 3D view of the valves from the LA Potential clinical applications Clinical applications • LA size and function measurements • Transcatheter interventional procedures requiring transseptal puncture: • ablation for atrial fibrillation (AF), focal atrial tachycardia (left atrial appendage closure, • mitral valve reconstruction • Diagnosis and closure of ASD • Patent foramen ovale • LAA measurement and closure • LA mass LA size measurements • Normal LA volume 22 ± 6 mL/m2 • Dilation of the LA: Diastolic dysfunction atrial flutter or fibrillation significant mitral valve disease bradycardia and 4-chamber enlargement, anemia and other high-output states - elite athletes - • LA volume index ≥ 34 mL/m2 is an independent predictor of: - death, - heart failure, - atrial fibrillation, - and ischemic strokes Lang RM, Eur J Echocardiogr 2006;7:79-108. Nagueh SF, Eur J Echocardiogr 2009;10:165-93. Tsang TSM, Am J Cardiol 2002;90: 1284-89. LA volume measurement by 3D echo 2D biplane area-length VS. 3D measurement 3D: underestimation 8% Miyasaka Y, J Am Soc Echocardiogr 2011;24:680-6. VS. CT measurement 2D: underestimation 19% LA volume: additional value of 3D echo? • Good correlation between 2D and 3D measurements • Absence of demonstration of an incremental prognostic value of the 3D measurements LA vol <50mL LA vol ≥50mL Jenkins C, J Am Soc Echocardiogr 2005;18:991-997. Anwar AM, Int J Cardiol 2008;123:155–61. Blume G, Eur J Echocardiogr 2011;12:421-30. LA function • 3 phases: • Reservoir: LA stores PV return during LV contraction and isovolumetric relaxation • Conduit: the LA transfers blood passively into the LV • Active contraction: contributes between 15 and 30% of LV stroke volume Blume G, Eur J Echocardiogr 2011;12:421-30. Determinants of LA function • LA size and function are influenced by LV compliance • LA afterload is determined by: • Elastic properties • LV compliance (elevated LV filling pressures = increased LA afterload) • LA preload: • Volume-dependent • Similar to the LV Frank– Starling curve, • LA size increases with LA volume and pressure => gain of contractility • Threshold fibre length => atrial shortening and contractility begin to decline Blume G, Eur J Echocardiogr 2011;12:421-30. Rosca M, Heart 2011; 97: 1982-1989. Assessment of LA function by echocardiography PW Doppler evaluation of transmitral flow PW Doppler evaluation of pulmonary veinous flow Measurements of atrial myocardial velocities Calculation of LA phasic volumes Measurements of atrial deformation Role of 3D echo in LA function assessment? 3D TEE-guided trans-septal punction • Potential additional value of 3D TEE vs. 2D TEE: • Facilitate understanding the morphology of the IAS • Valuable in patients at high risk for TSP: extreme rotation of the cardiac axis, repeated TSP, small size of fossa ovalis, or aneurismal IAS • Facilitate the recognition of the most appropriate site for the puncture 3D TEE-guided transseptal punction • 24 patients transeptal punction for AF ablation • Fossa ovalis clearly seen in all 24 patients. • All punctures required a single attempt to access left atrium. • Total fluoroscopic time was 120.6 + 34 s. • No major or minor complications were experienced. Cherchia GB, Europace 2008;10:1325-28. Ablation procedures Isolation of pulmonary veins in a patient with paroxysmal AF Faletra FF, JACC CVI 2011;4:203-206. ASD diagnosis and 3D echo Courtesy of Dr Hélène Thibault ASD diagnosis and 3D echo Facilitates the diagnosis of multiple complex defects ASD diagnosis and 3D echo Facilitates measurement of the borders and area of the ASD Courtesy of Dr Hélène Thibault ASD diagnosis and 3D TTE • Crossover study • 3D TTE vs. 2D TEE • 24 successive patients with ASD => 25% with poor quality 3D data • 12 normal subjects => No false positive • Complete agreement between the 3D and TEE regarding suitability in 15 patients (83%) Morgan GJ, Eur J Echocardiogr 2008;9:478-482. ASD closure and 3D echo Patent foramen ovale • FO= part of the normal fetal circulation • Birth: increase in pulmonary blood flow => increased LA pressure => compression septum primum against the septum secundum => FO closure • Anatomic closure incomplete: 25% adults • Possible association of PFO with cryptogenic strokes: – prevalence 50 to 60% vs. 25% in the normal population – but no demonstration in prospective studies that PFO is an independent factor of stroke Kutty S , J Am Coll Cardiol 2012;59:1665-71. Overell JR, Neurology 2000;55:1172-9. Patent foramen ovale TTE or TEE with agitated saline contrast Valsava maneuver Potential additional value of 3D TEE Rana BS , Eur J Echocardiogr 2010;11:i19-i25. Patent foramen ovale and 3D echo RT3D-TEE can be useful to guide PFO device closure procedure LAA measurements by 3DTEE • Assessment of LAA orifice area: Higher correlation of RT3DTEE (than 2DTEE) with CT • Underestimation of LAA orifice area by RT3DTEE and 2DTEE • But smaller bias with RT3DTEE (0.07 cm2) than 2DTEE (0.72 cm2) Nucifora G , Circ Cardiovasc Imaging 2011;4:514-23. Percutaneous LAA occlusion and 3D echo • Patients with AF/ alternative of chronic antithrombotic therapy • Preliminary results: feasibility and short-term success rate • PROTECT-AF: Non-inferiority • RT-3D echo is useful: • Before the procedure: to assess anatomical suitability, measure the ostium and detect contraindications (thrombus) • During the procedure: trans-septal punction and device positioning • At the end of the procedure: presence of residual communication between the LAA and the main LA • At follow-up: obliteration of the LAA and detection of procedure complications. Perk G , Eur Heart J CVI 2012;13:132-8. Holmes DR, Lancet 2009;374:534 – 542. Percutaneous LAA occlusion and 3D echo Courtesy of Dr Marielle Scherrer-Crosbie LA mass Conclusions • Imaging of the left atrium is important in clinical practice - Because LA size is a major prognostic factor of death, heart failure, atrial fibrillation, and ischemic stroke - for the diagnosis of PFO and ASD - for guided interventional procedures requiring trans-septal puncture. • 3D echo allows a comprehensive evaluation of LA anatomy and function. • Although the additional diagnostic and prognostic value of three-dimensional echo remains to be demonstrated in a large part of those pathologies/procedures, 3D echo is promising in those settings.