Methodological Gaps in Left Atrial Function Assessment by 2D Speckle Tracking Echocardiography

The assessment of left atrial (LA) function is used in various cardiovascular diseases. LA plays a complementary role in cardiac performance by modulating left ventricular (LV) function. Transthoracic two-dimensional (2D) phasic volumes and Doppler echocardiography can measure LA function non‑invasively. However, evaluation of LA deformation derived from 2D speckle tracking echocardiography (STE) is a new feasible and promising approach for assessment of LA mechanics. These parameters are able to detect subclinical LA dysfunction in different pathological condition. Normal ranges for LA deformation and cut-off values to diagnose LA dysfunction with different diseases have been reported, but data are still conflicting, probably because of some methodological and technical issues. This review highlights the importance of an unique standardized technique to assess the LA phasic functions by STE, and discusses recent studies on the most important clinical applications of this technique.

Keywords
Atrial Function, Left; Heart Atria / abnormalities; Echocardiography; Diagnostic Imaging

Authorship

Roxana Cristina Rimbaş

University and Emergency Hospital, Bucharest – RomaniaUniversity and Emergency HospitalRomaniaBucharest, RomaniaUniversity and Emergency Hospital, Bucharest – Romania

University of Medicine and Pharmacy Carol Davila, Bucharest – RomaniaUniversity of Medicine and Pharmacy Carol DavilaRomaniaBucharest, RomaniaUniversity of Medicine and Pharmacy Carol Davila, Bucharest – Romania

"Victor Babeş" National Institute of Pathology, Bucharest – Romania"Victor Babeş" National Institute of PathologyRomaniaBucharest, Romania"Victor Babeş" National Institute of Pathology, Bucharest – Romania

Raluca Elena Dulgheru

Dragoş Vinereanu Mailing Address: Dragoş Vinereanu University of Medicine and Pharmacy Carol Davila. Bucharest – Romania. E-mail: vinereanu@gmail.com

University and Emergency Hospital, Bucharest – RomaniaUniversity and Emergency HospitalRomaniaBucharest, RomaniaUniversity and Emergency Hospital, Bucharest – Romania

Mailing Address: Dragoş Vinereanu University of Medicine and Pharmacy Carol Davila. Bucharest – Romania. E-mail: vinereanu@gmail.com

Author contributions

Conception and design of the research and Writing of the manuscript: Rimbaş RC, Dulgheru RE, Vinereanu D; Acquisition of data and Analysis and interpretation of the data: Rimbaş RC, Dulgheru RE; Critical revision of the manuscript for intellectual content: Rimbaş RC, Vinereanu D.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

SCIMAGO INSTITUTIONS RANKINGS

University and Emergency Hospital, Bucharest – RomaniaUniversity and Emergency HospitalRomaniaBucharest, RomaniaUniversity and Emergency Hospital, Bucharest – Romania

Figures

Figures (8)

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Figure 1
"Bull’s eye" view of the longitudinal 2D strain of the left atrial contraction in a normal subject. It is coded in red because it represents the atrial strain of the pump function. Basal values are higher than medial values, and further reduced in the center, which represents the atrial roof (light red). Antero-lateral values are lower than infero-posterior values. Values of the antero-septal wall were excluded, because they correspond to the ascending aorta.

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Figure 2
Quad view of the longitudinal LA strain by 2DSTE. 2DSTE of the left atrium (LA) from the 2C view, depicting the region of interest (ROI) created by the STE software (panel A), and the corresponding regional strain values of the atrial function (panel B). In panel C, LA strain curves for each of the 6 segments are analyzed. The dashed curve represents the mean LA longitudinal strain. Reference point was placed at the onset of the P-wave. During the period in which the atrium acts as a reservoir atrial strain increases, reaching a peak just before mitral valve opening. During the conduit function, atrial strain decreases, with a plateau during diastasis, and a negative peak at the end of atrial contraction. In panel D, curved M-mode shows that atrial roof positive strain is lower (in light blue) than the other walls (in dark blue).

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Figure 3
Measurement of parameters of left atrial longitudinal strain by 2DSTE. 2C view depicting the region of interest and curved M-mode created by the software (left), and the corresponding global left atrial longitudinal strain (right); AVC: Aortic valve closure. The reference point was placed at the onset of the P wave, allowing measurement of the negative global strain at maximal atrial contraction (GSA-) (pump function), positive global strain at mitral valve opening (GSA+) (conduit function), and also sum of GSA- and GSA+ (TGSA) (reservoir function).

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Figure 4
Measurement of parameters of left atrial longitudinal strain rate by 2DSTE. 4C view depicting the region of interest created by the software (left), and the corresponding left atrial global longitudinal strain rate (right). GSR+, first positive global strain rate at the beginning of left ventricular systole; TGSR+, time from the P wave onset to peak positive strain rate; GSRE, early diastolic strain rate; GSRL, late diastolic strain rate.

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Figure 5
Comparison between the P-wave and the R-wave methods, for LA phasic function. 4C view depicting the region of interest (ROI) (left), and the corresponding LA strain curves (right). The dashed curves represent the mean global atrial longitudinal strains along the cardiac cycle. The reference point was placed at the onset of the P-wave (panel A), and at the R-wave (panel B). MVC: Mitral valve closure; AVC: Aortic valve closure; MVO: Mitral valve opening.

Panel A - Measurement of the negative global strain at atrial contraction (GSA-), the positive global strain at MVO (GSA+), and the total strain (TGSA) as a sum between GSA- and GSA+. The pump (AC), reservoir, and conduit functions are depicted. In the left inferior panel there is a clear delineation of the LA pump (red) and reservoir function (blue), with curved M-mode profile.

Panel B - Measurement of the total positive global strain at MVO (TGSA) (reservoir), and late positive global strain (GSAC) at the atrial contraction. There is a positive strain for atrial pump function with this method. The conduit function is defined as a difference between TGSA and GSAC. In the left inferior panel there is no delineation at all for the LA contraction and reservoir function (all blue), with curved M-mode profile.

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Figure 6
Comparison between left atrial strain in a patient with reccurent atrial fibrillation (panel A) and in a normal subject (panel B).

Averaged strain (dotted line) is markedly reduced in the patient with reccurent atrial fibrillation during the pump function (GSA-) (-3% vs. -15%), during the conduit function (GSA+) (9% vs. 18%), and during the reservoir function (TGSA) (13% vs. 33%). There is also a complete dyssynchrony of contraction and relaxation between left atrial segments in the patient with atrial fibrillation versus the normal subject.

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Figure 7
Comparison between left atrial strain in a patient with hypertrophic cardiomyopathy (panel A) and in a normal subject (panel B).

Averaged strain is markedly reduced in the patient with hypertrophic cardiomyopathy during the pump function (GSA-) (-4% vs. -10%), during the conduit phase (GSA+) (8% vs. 26%), and during the reservoir phase (TGSA) (12% vs. 36%).

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Figure 8
Comparison between left atrial strain in a patient with idiopathic dilated cardiomyopathy, before (panel A) and after (panel B) cardiac resynchronization therapy (CRT). Averaged strain is markedly reduced before than after CRT during the pump function (GSA-) (-5.1% vs. -9%), during the conduit function (GSA+) (2.4% vs. 5%), and also during the reservoir function (TGSA) (7.5% vs. 14%). A significant improvement of the atrial synchrony for both pump and reservoir functions was observed after CRT (panel B), compared to a complete disorganized pattern of strain before CRT (panel A).

Figure 1 "Bull’s eye" view of the longitudinal 2D strain of the left atrial contraction in a normal subject. It is coded in red because it represents the atrial strain of the pump function. Basal values are higher than medial values, and further reduced in the center, which represents the atrial roof (light red). Antero-lateral values are lower than infero-posterior values. Values of the antero-septal wall were excluded, because they correspond to the ascending aorta.

Figure 2 Quad view of the longitudinal LA strain by 2DSTE. 2DSTE of the left atrium (LA) from the 2C view, depicting the region of interest (ROI) created by the STE software (panel A), and the corresponding regional strain values of the atrial function (panel B). In panel C, LA strain curves for each of the 6 segments are analyzed. The dashed curve represents the mean LA longitudinal strain. Reference point was placed at the onset of the P-wave. During the period in which the atrium acts as a reservoir atrial strain increases, reaching a peak just before mitral valve opening. During the conduit function, atrial strain decreases, with a plateau during diastasis, and a negative peak at the end of atrial contraction. In panel D, curved M-mode shows that atrial roof positive strain is lower (in light blue) than the other walls (in dark blue).

Figure 3 Measurement of parameters of left atrial longitudinal strain by 2DSTE. 2C view depicting the region of interest and curved M-mode created by the software (left), and the corresponding global left atrial longitudinal strain (right); AVC: Aortic valve closure. The reference point was placed at the onset of the P wave, allowing measurement of the negative global strain at maximal atrial contraction (GSA-) (pump function), positive global strain at mitral valve opening (GSA+) (conduit function), and also sum of GSA- and GSA+ (TGSA) (reservoir function).

Figure 4 Measurement of parameters of left atrial longitudinal strain rate by 2DSTE. 4C view depicting the region of interest created by the software (left), and the corresponding left atrial global longitudinal strain rate (right). GSR+, first positive global strain rate at the beginning of left ventricular systole; TGSR+, time from the P wave onset to peak positive strain rate; GSRE, early diastolic strain rate; GSRL, late diastolic strain rate.

Figure 5 Comparison between the P-wave and the R-wave methods, for LA phasic function. 4C view depicting the region of interest (ROI) (left), and the corresponding LA strain curves (right). The dashed curves represent the mean global atrial longitudinal strains along the cardiac cycle. The reference point was placed at the onset of the P-wave (panel A), and at the R-wave (panel B). MVC: Mitral valve closure; AVC: Aortic valve closure; MVO: Mitral valve opening.
Panel A - Measurement of the negative global strain at atrial contraction (GSA-), the positive global strain at MVO (GSA+), and the total strain (TGSA) as a sum between GSA- and GSA+. The pump (AC), reservoir, and conduit functions are depicted. In the left inferior panel there is a clear delineation of the LA pump (red) and reservoir function (blue), with curved M-mode profile.

Panel B - Measurement of the total positive global strain at MVO (TGSA) (reservoir), and late positive global strain (GSAC) at the atrial contraction. There is a positive strain for atrial pump function with this method. The conduit function is defined as a difference between TGSA and GSAC. In the left inferior panel there is no delineation at all for the LA contraction and reservoir function (all blue), with curved M-mode profile.

Figure 4 Measurement of parameters of left atrial longitudinal strain rate by 2DSTE. 4C view depicting the region of interest created by the software (left), and the corresponding left atrial global longitudinal strain rate (right). GSR+, first positive global strain rate at the beginning of left ventricular systole; TGSR+, time from the P wave onset to peak positive strain rate; GSRE, early diastolic strain rate; GSRL, late diastolic strain rate.

Figure 6 Comparison between left atrial strain in a patient with reccurent atrial fibrillation (panel A) and in a normal subject (panel B).
Averaged strain (dotted line) is markedly reduced in the patient with reccurent atrial fibrillation during the pump function (GSA-) (-3% vs. -15%), during the conduit function (GSA+) (9% vs. 18%), and during the reservoir function (TGSA) (13% vs. 33%). There is also a complete dyssynchrony of contraction and relaxation between left atrial segments in the patient with atrial fibrillation versus the normal subject.

Figure 7 Comparison between left atrial strain in a patient with hypertrophic cardiomyopathy (panel A) and in a normal subject (panel B).
Averaged strain is markedly reduced in the patient with hypertrophic cardiomyopathy during the pump function (GSA-) (-4% vs. -10%), during the conduit phase (GSA+) (8% vs. 26%), and during the reservoir phase (TGSA) (12% vs. 36%).

Figure 8 Comparison between left atrial strain in a patient with idiopathic dilated cardiomyopathy, before (panel A) and after (panel B) cardiac resynchronization therapy (CRT). Averaged strain is markedly reduced before than after CRT during the pump function (GSA-) (-5.1% vs. -9%), during the conduit function (GSA+) (2.4% vs. 5%), and also during the reservoir function (TGSA) (7.5% vs. 14%). A significant improvement of the atrial synchrony for both pump and reservoir functions was observed after CRT (panel B), compared to a complete disorganized pattern of strain before CRT (panel A).

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Methodological Gaps in Left Atrial Function Assessment by 2D Speckle Tracking Echocardiography

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[1] Mailing Address: Dragoş Vinereanu University of Medicine and Pharmacy Carol Davila. Bucharest – Romania. E-mail: vinereanu@gmail.com