Left atrial size measured on CT pulmonary angiography: another parameter of pulmonary embolism severity? A systematic review

  • Marco Zuin
  • Gianluca Rigatelli
  • Stefano Turchetta
  • Pietro Zonzin
  • Giovanni Zuliani
  • Loris RonconEmail author


We systematically review the potential role of left atrial (LA) size, evaluated at computed tomography angiography (CTA) in patients with acute pulmonary embolism (PE), as a new parameter of PE severity. A literature search based on PubMed (MEDLINE), Scopus, Cochrane library and Google Scholar databases was performed to locate previous published investigations reporting data on the severity of acute PE based on the evaluation of LA size (either volume, diameter or area). Six studies, corresponding to a total of 990 patients, published between 2012 and 2019 were included into the analysis. The severity of acute PE, in terms of hemodynamic impairment, increases with the reduction of the LA volume and a significant negative correlation was observed between the pulmonary artery obstruction index (PAOI) and the LA area. Similarly, the longest left-to-right as well as the anteroposterior diameters of the LA had a significant positive correlation with the PAOI index for both the measurement. The LA volume significantly decreased with the increasing of the PAOI index. Moreover, a lower LA volume was observed in those subjects with a saddle PE appearing as the best single parameter able to discriminate between patients having or not a saddle acute PE. Intriguingly, PE patients died within 30 days from the acute event had a significant small LA volume compared to survivors. Data obtained from the current medical literature seem to suggest that the evaluation of LA size evaluation could be a new parameter of PE severity. Further and larger prospective studies are needed to confirm preliminary findings.


Pulmonary embolism Left atrium size Computed tomography angiography 




Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Zuin M, Rigatelli G, Picariello C, Carraro M, Zonzin P, Roncon L (2017) Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean Arterial Pressure Index (AMAPI). Heart Vessels 32:1478–1487CrossRefGoogle Scholar
  2. 2.
    Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M, Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) (2014) 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J35:3033–3069Google Scholar
  3. 3.
    Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L (2016) Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 149:315–352CrossRefGoogle Scholar
  4. 4.
    Becattini C, Agnelli G, Germini F, Vedovati MC (2014) Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis. Eur Respir J 43:1678–1690CrossRefGoogle Scholar
  5. 5.
    Becattini C, Agnelli G, Vedovati MC, Pruszczyk P, Casazza F, Grifoni S, Salvi A, Bianchi M, Douma R, Konstantinides S, Lankeit M, Duranti M (2011) Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J 32:1657–1663CrossRefGoogle Scholar
  6. 6.
    Meinel FG, Nance JW Jr, Schoepf UJ, Hoffmann VS, Thierfelder KM, Costello P, Goldhaber SZ, Bamberg F (2015) Predictive value of computed tomography in acute pulmonary embolism: systematic review and meta-analysis. Am J Med 128:747–759CrossRefGoogle Scholar
  7. 7.
    Aslan K, Polat AV, Güzel A, Öztürk M (2019) Assessment of the association between pre-treatment and post-treatment left atrium size and severity of disease in patients with acute pulmonary embolism by using computed tomography pulmonary angiography. Tuberk Toraks 67:1–7CrossRefGoogle Scholar
  8. 8.
    Langroudi TF, Sheikh M, Naderian M, Taheri MS, Ashraf-ganjouei A, Khaheshi IB (2019) The association between the pulmonary arterial obstruction index and atrial size in patients with acute pulmonary embolism. Radiol Res Pract. CrossRefGoogle Scholar
  9. 9.
    Guo ZJ, Liu HT, Bai ZM, Lin Q, Zhao BH, Xu Q, Zeng YH, Feng WQ, Zhou HT, Liang F, Cui JY (2018) A new method of CT for the cardiac measurement: correlation of computed tomography measured cardiac parameters and pulmonary obstruction index to assess cardiac morphological changes in acute pulmonary embolism patients. J Thromb Thrombolysis 45:410–416CrossRefGoogle Scholar
  10. 10.
    Aviram G, Soikher E, Bendet A, Ziv-Baran T, Berliner S, Shmueli H, Friedensohn L, Milwidsky A, Sadovnik O, Topilsky Y (2016) Automatic assessment of cardiac load due to acute pulmonary embolism: Saddle vs. central and peripheral emboli distribution. Heart Lung 45:261–269CrossRefGoogle Scholar
  11. 11.
    Aviram G, Soikher E, Bendet A, Shmueli H, Ziv-Baran T, Amitai Y, Friedensohn L, Berliner S, Meilik A, Topilsky Y (2016) Prediction of mortality in pulmonary embolism based on left atrial volume measured on CT pulmonary angiography. Chest 149:667–675CrossRefGoogle Scholar
  12. 12.
    Aviram G, Sirota-Cohen C, Steinvil A, Keren G, Banai S, Sosna J, Berliner S, Rogowski O (2012) Automated volumetric analysis of four cardiac chambers in pulmonary embolism: a novel technology for fast risk stratification. Thromb Haemost 108:384–393CrossRefGoogle Scholar
  13. 13.
    Ocak I, Fuhrman C (2008) CT angiography findings of the left atrium and right ventricle in patients with massive pulmonary embolism. AJR Am J Roentgenol 191:1072–1076CrossRefGoogle Scholar
  14. 14.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535CrossRefGoogle Scholar
  15. 15.
    Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, Barré O, Bruckert F, Dubourg O, Lacombe P (2001) New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 176:1415–1420CrossRefGoogle Scholar
  16. 16.
    Elliott CG (1992) Pulmonary physiology during pulmonary embolism. Chest 101:163S–171SCrossRefGoogle Scholar
  17. 17.
    Chua J, Zhou W, Ho JK, Patel NA, Mackensen GB, Mahajan A (1985) Acute right ventricular pressure overload compromises left ventricular function by altering septal strain and rotation. J Appl Physiol 115:186–193CrossRefGoogle Scholar
  18. 18.
    Matthews JC, McLaughlin V (2008) Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 4:49–59CrossRefGoogle Scholar
  19. 19.
    Chung T, Emmett L, Khoury V, Lau GT, Elsik M, Foo F, Allman KC, Kritharides L (2006) Atrial and ventricular echocardiographic correlates of the extent of pulmonary embolism in the elderly. J Am Soc Echocardiogr 19:347–353CrossRefGoogle Scholar
  20. 20.
    Meyer G (2014) Effective diagnosis and treatment of pulmonary embolism: improving patient outcomes. Arch Cardiovasc Dis 107:406–414CrossRefGoogle Scholar
  21. 21.
    Merli GJ (2017) Pulmonary embolism in 2017: how we got here and where are we going? Tech Vasc Interv Radiol 20:128–134CrossRefGoogle Scholar
  22. 22.
    Shen C, Yu N, Wen L, Zhou S, Dong F, Liu M, Guo Y (2019) Risk stratification of acute pulmonary embolism based on the clot volume and right ventricular dysfunction on CT pulmonary angiography. Clin Respir J. CrossRefPubMedGoogle Scholar
  23. 23.
    Mastora I, Remy-Jardin M, Masson P, Galland E, Delannoy V, Bauchart JJ, Remy J (2003) Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data. Eur Radiol 13:29–35CrossRefGoogle Scholar
  24. 24.
    Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ (2005) Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med 172:1041–1046CrossRefGoogle Scholar
  25. 25.
    Jiménez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, Otero R, Monreal M, Muriel A, Yusen RD, Investigators RIETE (2010) Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170:1383–1389CrossRefGoogle Scholar
  26. 26.
    Kang DK, Thilo C, Schoepf UJ, Barraza JM Jr, Nance JW Jr, Bastarrika G, Abro JA, Ravenel JG, Costello P, Goldhaber SZ (2011) CT signs of right ventricular dysfunction: prognostic role in acute pulmonary embolism. JACC Cardiovasc Imaging 4:841–849CrossRefGoogle Scholar
  27. 27.
    Kumamaru KK, Saboo SS, Aghayev A, Cai P, Quesada CG, George E, Hussain Z, Cai T, Rybicki FJ (2016) CT pulmonary angiography-based scoring system to predict the prognosis of acute pulmonary embolism. J Cardiovasc Comput Tomogr 10:473–479CrossRefGoogle Scholar
  28. 28.
    Liu M, Miao R, Guo X, Zhu L, Zhang H, Hou Q, Guo Y, Yang Y (2017) Saddle pulmonary embolism: laboratory and computed tomographic pulmonary angiographic findings to predict short-term mortality. Heart Lung Circ 26:134–142CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Section of Internal and Cardiopulmonary MedicineUniversity of FerraraFerraraItaly
  2. 2.Cardiovascular Diagnosis and Endoluminal Interventions UnitRovigo General HospitalRovigoItaly
  3. 3.Department of RadiologyPorto Viro General HospitalPorto ViroItaly
  4. 4.Division of CardiologyRovigo General HospitalRovigoItaly
  5. 5.Department of CardiologySanta Maria della Misericordia HospitalRovigoItaly

Personalised recommendations