Reliability of left atrial strain reference values: A 3D echocardiographic study.

Yosuke Nabeshima,Masaaki Takeuchi,Tetsuji Kitano,Kumaradevan Punithakumar

doi:10.1371/journal.pone.0250089

Yosuke Nabeshima, Masaaki Takeuchi + Show 2 more

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https://doi.org/10.1371/journal.pone.0250089

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Abstract

Standard apical four-chamber and two-chamber views often maximize the long-axis of the left ventricle, resulting in artifactitious foreshortening of the left atrium (LA), which may overestimate LA longitudinal reservoir strain (LALS). We compared LALS values between 2D echocardiography (2DE) and 3D echocardiography (3DE) in healthy subjects to determine whether 2DE speckle tracking analysis overestimates the reference value of LALS. In this study, 4 types of cohorts were included: 1. 105 normal subjects (retrospectively), 2. 53 patients with cardiovascular diseases (retrospectively), 3. 15 patients who received cardiac magnetic resonance (prospectively), and 4. 20 normal subjects (prospectively). LALS and LA length were measured using both 2DE and 3DE in 105 healthy subjects (median age: 42 years). Biplane LALS was measured in apical four- and two-chamber views using 2DE speckle tracking software, and 3DE LALS was measured using new 3DE LA strain software. To determine sensitivity, we also performed the same analysis in 53 patients with cardiovascular disease. The mean value of biplane LALS was 39.6%. LA length at both end-diastole (r = -0.43) and end-systole (r = -0.54) was negatively correlated with biplane LALS. Multivariate regression analysis revealed that both end-diastolic and end-systolic LA length had significant negative relationships with biplane LALS after adjusting for anthropometric and echocardiographic image quality parameters. 3DE LALS (23.7±7.6%) gave significantly lower values than 2DE LALS (39.5±12.0%, p<0.001) with a weak correlation (r = 0.33). LA length measured by 2DE was significantly shorter than that measured by 3DE. The same trend was observed in diseased patients. Our results revealed that in 2DE, the LA cavity consistently appears longitudinally foreshortened in apical views, potentially overestimating LALS. 3DE may overcome this limitation.

Highlights

The left atrium is responsible for left ventricular (LV) diastolic filling; its volumetric and mechanical changes reflect the degree and chronicity of LV diastolic dysfunction [1, 2]
Our results revealed that in 2D echocardiography (2DE), the left atrium (LA) cavity consistently appears longitudinally foreshortened in apical views, potentially overestimating longitudinal reservoir strain (LALS). 3D echocardiography (3DE) may overcome this limitation
We hypothesized that a foreshortened LA view could overestimate 2DE LA strain because it reduces the initial perimeter of the region of interest (ROI), which is the denominator of the strain calculation

Summary

Introduction

The left atrium is responsible for left ventricular (LV) diastolic filling; its volumetric and mechanical changes reflect the degree and chronicity of LV diastolic dysfunction [1, 2]. Left atrial (LA) longitudinal strain, assessed by two-dimensional echocardiography (2DE) speckle tracking analysis, has become increasingly common for estimating LV diastolic dysfunction [3,4,5] and for predicting outcomes [6, 7]. The standardization task force of the European Association of Cardiovascular Imaging and the American Society of Echocardiography recommends that “LA strain should be measured using a non-foreshortened apical fourchamber view of the left atrium” [9]. Voigt et al recently published a methodological paper explaining how to measure 2D LA strain [12], in which they presented a case indicating that a foreshortened LA image results in higher LA strain. Standard apical four-chamber and two-chamber views often maximize the long-axis of the left ventricle, resulting in artifactitious foreshortening of the left atrium (LA), which may overestimate LA longitudinal reservoir strain (LALS). We compared LALS values between 2D echocardiography (2DE) and 3D echocardiography (3DE) in healthy subjects to determine whether 2DE speckle tracking analysis overestimates the reference value of LALS

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