Left atriomegaly

2D imaging views: upper left: apical 4-chamber; upper right: apical 2-chamber; lower left: apical 3-chamber (long axis); lower right: subcostal 4-chamber. Images courtesy of dr. Fabrizio Celeste.

#tt3662. Extreme left atrial dilatation (atriomegaly) in 83 y.o patient with permanent atrial fibrillation, chronic coronary artery disease, arterial hypertension,  and previous surgical mitral valvuloplasty. NYHA class II.
Left ventricular (LV) biplane end-diastolic volume index= 60 ml/m2; LV ejection fraction= 62 %; moderate mitral regurgitation with no significant restriction to LV inflow (mean diastolic transmitral gradient= 6 mmHg).

End-systolic (maximum) left atrial volume: 4-chamber= 1866 ml; 2-chamber= 1137 ml; biplane (modified Simpson’s rule)= 1426 ml (801 ml/m2).

Planimetry of the left atrium in 4-chamber view

Planimetry of the left atrium in 4-chamber view

Chest X-ray, antero-post

Chest X-ray, antero-post

Chest X-ray, lateral

Chest X-ray, lateral

On chest X-ray, the left atrium spans the entire width of the thorax.



Measurement of Pulmonary Diastolic Pressure

Color Doppler, parasternal short axis view of the base of the heart, with leftward tilt of transducer to image pulmonary valve and right ventricular outflow tract (RVOT).

Mild, central pulmonary valve regurgitation is evidenced (red / yellow jet directed towards anterior wall of RVOT). Subsequently, Continuous wave Doppler scan line is placed parallel and central to regurgitant jet to record diastolic velocities (see below).

Peak end-diastolic regurgitant velocity (+) is measured after the indentation (arrows) caused by right atrial contraction. Using the simplified Bernouilli equation, the ultrasound machine displays the corresponding pressure gradient occurring in end-diastole between the pulmonary artery and the right ventricle (RV).

The diastolic (=end-diastolic) pulmonary artery pressure is calculated by adding the estimated (observing the degree of inferior vena cava inspiratory collapse , 2D subcostal imaging) right atrial pressure (= to RV end-diastolic pressure) to the pul,onary artery – RV pressure gradient.

Pulmonary artery diastolic pressure = (pulmonary artery – RV pressure gradient) + right atrial pressure

Mild Pericardial Effusion

#3791 – Male, 75 y., mild chronic pericardial effusion (diffuse) in coronary artery disease. Apical 4-chamber view centered on the right side. Note two rapid inward motions of the lateral right atrial wall at ventricular end-diastole and end-systole.

Figure below (anatomical M-mode of the right atrial lateral wall):

A. inward motion of right atrial wall secondary to atrial contraction (follows ECG P wave).

B. right atrial wall early systolic inward motion (passive collapse) secondary to mild increase in pericardial pressure, which exceeds right atrial pressure at “x” pressure nadir (of the right atrial pressure wave).

M-mode sequence of right atrial contraction and collapse

M-mode sequence of right atrial contraction and collapse

Wall motion analysis: apical inferior septum

Comparison of normal vs. typical cases of abnormal wall motion of the apical septum:

1. (upper left) Normal

2. (upper right) Akynesia

3. (lower left) Aneurysm (abnormal diastolic left ventricular geometry with systolic expansion)

4. (lower right) Extensive dyskinesis secondary to pacemaker activation (electrode in right ventricular apex)

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