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Normal ranges of left atrial volumes and ejection fraction by 3D echocardiography in adults: a systematic review and meta-analysis

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Abstract

Increased sizes and dysfunction of the left atrium have been related to adverse outcomes. 3D-echocardiography is more accurate than 2D-echocardiography in estimating LA volumes and ejection fraction. However, the use of 3DE for LA analysis is limited by the absence of established reference values. We performed a systematic review and meta-analysis to provide reference ranges of LA maximum and minimum volumes indexed for body surface area (LAVi max and LAVi min, respectively), and LA-EF assessed by 3DE in healthy adults. Data search was conducted from inception through September 15, 2021, using the following Medical Subject Heading terms: left atrial/atrium, three-dimensional/3D echocardiography. The study protocol was registered in the PROSPERO database (CRD42021252428). 15 studies including 4,226 healthy adults (51% males) and reporting 3DE values of LAVi max, LAVi min and LA-EF were selected. LAVi max, LAVi min and LA-EF mean and reference values were equal to 25.18 ml/m2 (95% CI 23.10, 27.26), 11.10 ml/m2 (10.01, 12.18) and 55.94% (51.92, 59.96), respectively. No influential studies were identified. Pooled estimates per age group- and sex were also estimated. By meta-regression analyses, we identified variability in LA volumes and LA-EF depending on participants’ age, ethnicity and number of heart cycles at 3D multi-beat acquisition. At individual patient data analysis conducted on 374 subjects, a software effect on LA-EF was shown. This systematic review and meta-analysis provides reference values of LAVi max, LAVi min and LA-EF assessed by 3DE in healthy adults, encouraging 3DE evaluation of the LA evaluation in daily practice.

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References

  1. Thomas L, Muraru D, Popescu BA, Sitges M, Rosca M, Pedrizzetti G, Henein MY, Donal E, Badano LP (2020) Evaluation of left atrial size and function: relevance for clinical practice. J Am Soc Echocardiogr 33:934–952. https://doi.org/10.1016/j.echo.2020.03.021

    Article  PubMed  Google Scholar 

  2. Thomas L, Marwick TH, Popescu BA, Donal E, Badano LP (2019) Left atrial structure and function, and left ventricular diastolic dysfunction: JACC State-of-the-Art review. J Am Coll Cardiol 73:1961–1977. https://doi.org/10.1016/j.jacc.2019.01.059

    Article  PubMed  Google Scholar 

  3. Mor-Avi V, Yodwut C, Jenkins C, Khl H, Nesser HJ, Marwick TH, Franke A, Weinert L, Niel J, Steringer-Mascherbauer R, Freed BH, Sugeng L, Lang RM (2012) Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with CMR. JACC Cardiovasc Imaging 5:769–777. https://doi.org/10.1016/j.jcmg.2012.05.011

    Article  PubMed  Google Scholar 

  4. Singh A, Carvalho Singulane C, Miyoshi T, Prado AD, Addetia K, Bellino M, Daimon M, Gutierrez Fajardo P, Kasliwal RR, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Ronderos RE, Sadeghpour A, Scalia GM, Takeuchi M, Tsang W, Tucay ES, Rodrigues ACT, Vivekanandan A, Zhang Y, Schreckenberg M, Blankenhagen M, Degel M, Hitschrich N, Mor-Avi V, Asch FM, Lang RM, WASE Investigators (2021) Normal values of left atrial size and function and the impact of age: results of the world alliance societies of echocardiography study. J Am Soc Echocardiogr. https://doi.org/10.1016/j.echo.2021.08.008

    Article  PubMed  PubMed Central  Google Scholar 

  5. Aune E, Baekkevar M, Roislien J, Rodevand O, Otterstad JE (2009) Normal reference ranges for left and right atrial volume indexes and ejection fractions obtained with real-time three-dimensional echocardiography. Eur J Echocardiogr 10:738–744. https://doi.org/10.1093/ejechocard/jep054

    Article  PubMed  Google Scholar 

  6. Badano LP, Miglioranza MH, MihǍilǍ S, Peluso D, Xhaxho J, Marra MP, Cucchini U, Soriani N, Iliceto S, Muraru D (2016) Left atrial volumes and function by three-dimensional echocardiography: reference values, accuracy, reproducibility, and comparison with two-dimensional echocardiographic measurements. Circ Cardiovasc Imaging 9:1–12. https://doi.org/10.1161/CIRCIMAGING.115.004229

    Article  Google Scholar 

  7. Wu VCC, Takeuchi M, Kuwaki H, Iwataki M, Nagata Y, Otani K, Haruki N, Yoshitani H, Tamura M, Abe H, Negishi K, Lin FC, Otsuji Y (2013) Prognostic value of la volumes assessed by transthoracic 3D echocardiography: comparison with 2D echocardiography. J Am Coll Cardiol Img 6:1025–1035. https://doi.org/10.1016/j.jcmg.2013.08.002

    Article  Google Scholar 

  8. Moher D, Liberati A, Tetzlaff J, Altman DG, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. https://doi.org/10.7326/0003-4819-151-4-200908180-00135

    Article  PubMed  Google Scholar 

  9. Nabeshima Y, Kitano T, Takeuchi M (2021) Reliability of left atrial strain reference values: a 3D echocardiographic study. PLoS One 16:e0250089. https://doi.org/10.1371/journal.pone.0250089

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Takeuchi M, Kitano T, Nabeshima Y, Otsuji Y, Otani K (2019) Left ventricular and left atrial volume ratio assessed by three-dimensional echocardiography: novel indices for evaluating age-related change in left heart chamber size. Physiol Rep 7:e14300. https://doi.org/10.14814/phy2.14300

    Article  PubMed  PubMed Central  Google Scholar 

  11. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. https://doi.org/10.1007/s10654-010-9491-z

    Article  PubMed  Google Scholar 

  12. Pateras K, Nikolakopoulos S, Roes K (2018) Data-generating models of dichotomous outcomes: heterogeneity in simulation studies for a random-effects meta-analysis. Stat Med 37:1115–1124. https://doi.org/10.1002/sim.7569

    Article  PubMed  Google Scholar 

  13. Spineli LM, Pandis N (2020) Prediction interval in random-effects meta-analysis. Am J Orthod Dentofac Orthop 157:586–588. https://doi.org/10.1016/j.ajodo.2019.12.011

    Article  Google Scholar 

  14. Fukuda S, Watanabe H, Daimon M, Abe Y, Hirashiki A, Hirata K, Ito H, Iwai-Takano M, Iwakura K, Izumi C, Hidaka T, Yuasa T, Murata K, Nakatani S, Negishi K, Nishigami K, Nishikage T, Ota T, Hayashida A, Sakata K, Tanaka N, Yamada S, Yamamoto K, Yoshikawa J (2012) Normal values of real-time 3-dimensional echocardiographic parameters in a healthy Japanese population: the JAMP-3D Study. Circ J 76:1177–1181. https://doi.org/10.1253/circj.cj-11-1256

    Article  PubMed  Google Scholar 

  15. Bhambhani A, John N, Mathew A (2018) Real-time three-dimensional echocardiographic left heart parameters in healthy indian adults. Indian Heart J 70:642–648. https://doi.org/10.1016/j.ihj.2017.11.018

    Article  PubMed  Google Scholar 

  16. Onishi N, Kawasaki M, Tanaka R, Sato H, Saeki M, Nagaya M, Sato N, Minatoguchi S, Watanabe T, Ono K, Arai M, Noda T, Amano K, Goto K, Watanabe S, Minatoguchi S (2014) Comparison between left atrial features in well-controlled hypertensive patients and normal subjects assessed by three-dimensional speckle tracking echocardiography. J Cardiol 63:291–295. https://doi.org/10.1016/j.jjcc.2013.09.006

    Article  PubMed  Google Scholar 

  17. De Castro S, Caselli S, Di Angelantonio E, Del Colle S, Mirabelli F, Marcantonio A, Puccio D, Santini D, Pandian NG (2008) Relation of left atrial maximal volume measured by real-time 3D echocardiography to demographic, clinical, and Doppler variables. Am J Cardiol 101:1347–1352. https://doi.org/10.1016/j.amjcard.2008.01.005

    Article  Google Scholar 

  18. Azar F, de Pérez IL, Moreno M, Landaeta A, Refoyo E, Lópezernández T, Macaya C, Zamorano J (2009) Three-dimensional echocardiographic assessment of left atrial size and function and the normal range of asynchrony in healthy individuals. Rev Esp Cardiol 62:816–819. https://doi.org/10.1016/s1885-5857(09)72363-1

    Article  PubMed  Google Scholar 

  19. Nemes A, Kormányos Á, Domsik P, Kalapos A, Lengyel C, Forster T (2019) Normal reference values of three-dimensional speckle-tracking echocardiography-derived left atrial strain parameters (results from the MAGYAR-Healthy Study). Int J Cardiovasc Imaging 35:991–998. https://doi.org/10.1007/s10554-019-01559-z

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sugimoto T, Robinet S, Dulgheru R, Bernard A, Ilardi F, Contu L, Addetia K, Caballero L, Kacharava G, Athanassopoulos GD, Barone D, Baroni M, Cardim N, Hagendorff A, Hristova K, Lopez T, de Morena G, Popescu BA, Penicka M, Ozyigit T, Rodrigo Carbonero JD, van de Veire N, Von Bardeleben RS, Vinereanu D, Zamorano JL, Go YY, Marchetta S, Nchimi A, Rosca M, Calin A et al (2018) Echocardiographic reference ranges for normal left atrial function parameters: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging 19:630–638. https://doi.org/10.1093/ehjci/jey018

    Article  PubMed  Google Scholar 

  21. Zhong L, Tan LK, Finn CJ, Ghista D, Liew R, Ding ZP (2012) Effects of age and gender on left atrial ejection force and volume from real-time three-dimensional echocardiography. Ann Acad Med Singap 41:161–169

    Article  PubMed  Google Scholar 

  22. Saraiva RM, Scolin EMB, Pacheco NP, Bouret ME, Mediano MFF, Holanda MT, da Costa AR (2019) 3-Dimensional echocardiography and 2-D strain analysis of left ventricular, left atrial and right ventricular function in healthy Brazilian volunteers. Arq Bras Cardiol 113:935–945. https://doi.org/10.5935/abc.20190155

    Article  PubMed  PubMed Central  Google Scholar 

  23. Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D (1995) Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 92:835–841. https://doi.org/10.1161/01.cir.92.4.835

    Article  CAS  PubMed  Google Scholar 

  24. Santos ABS, Roca GQ, Claggett B, Sweitzer NK, Shah SJ, Anand IS, Fang JC, Zile MR, Pitt B, Solomon SD, Shah AM (2016) Prognostic relevance of left atrial dysfunction in heart failure with preserved ejection fraction. Circ Heart Fail 9:e002763. https://doi.org/10.1161/CIRCHEARTFAILURE.115.002763

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Thomas L, Abhayaratna WP (2017) Left atrial reverse remodeling: mechanisms, evaluation, and clinical significance. J Am Coll Cardciol Img 10:65–77. https://doi.org/10.1016/j.jcmg.2016.11.003

    Article  Google Scholar 

  26. Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, Tsang TSM (2006) Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol 47:2357–2363. https://doi.org/10.1016/j.jacc.2006.02.048

    Article  PubMed  Google Scholar 

  27. Russo C, Jin Z, Homma S, Rundek T, Elkind MSV, Sacco RL, Di Tullio MR (2017) LA phasic volumes and reservoir function in the elderly by real-time 3D echocardiography: normal values, prognostic significance, and clinical correlates. J Am Coll Cardiol Img 10:976–985. https://doi.org/10.1016/j.jcmg.2016.07.015

    Article  Google Scholar 

  28. Kühl JT, Lønborg J, Fuchs A, Andersen MJ, Vejlstrup N, Kelbæk H, Engstrøm T, Møller JE, Kofoed KF (2012) Assessment of left atrial volume and function: a comparative study between echocardiography, magnetic resonance imaging and multi slice computed tomography. Int J Cardiovasc Imaging 28:1061–1071. https://doi.org/10.1007/s10554-011-9930-2

    Article  PubMed  Google Scholar 

  29. Ho SY, McCarthy KP, Faletra FF (2011) Anatomy of the left atrium for interventional echocardiography. Eur J Echocardiogr 12:i11-5. https://doi.org/10.1093/ejechocard/jer093

    Article  PubMed  Google Scholar 

  30. O’Brien JP, Srichai MB, Hecht EM, Kim DC, Jacobs JE (2007) Anatomy of the heart at multidetector CT: what the radiologist needs to know. Radiographics 27:1569–1582. https://doi.org/10.1148/rg.276065747

    Article  PubMed  Google Scholar 

  31. Nunes MCP, Handschumacher MD, Levine RA, Barbosa MM, Carvalho VT, Esteves WA, Zeng X, Guerrero JL, Zheng H, Tan TC, Hung J (2014) Role of LA shape in predicting embolic cerebrovascular events in mitral stenosis: mechanistic insights from 3D echocardiography. J Am Coll Cardiol Img 7:453–461. https://doi.org/10.1016/j.jcmg.2014.01.013

    Article  Google Scholar 

  32. Mor-Avi V, Sugeng L, Lang RM (2009) Real-time 3-dimensional echocardiography: an integral component of the routine echocardiographic examination in adult patients? Circulation. https://doi.org/10.1161/CIRCULATIONAHA.107.751354

    Article  PubMed  Google Scholar 

  33. Hudsmith LE, Petersen SE, Francis JM, Robson MD, Neubauer S (2005) Normal human left and right ventricular and left atrial dimensions using steady state free precession magnetic resonance imaging. J Cardiovasc Magn Reson 7:775–782. https://doi.org/10.1080/10976640500295516

    Article  PubMed  Google Scholar 

  34. Natori S, Lai S, Finn JP, Gomes AS, Hundley WG, Jerosch-Herold M, Pearson G, Sinha S, Arai A, Lima JAC, Bluemke DA (2006) Cardiovascular function in multi-ethnic study of atherosclerosis: normal values by age, sex, and ethnicity. Am J Roentgenol 186:S357-65. https://doi.org/10.2214/AJR.04.1868

    Article  Google Scholar 

  35. Chahal NS, Lim TK, Jain P, Chambers JC, Kooner JS, Senior R (2012) Population-based reference values for 3D echocardiographic LV volumes and ejection fraction. J Am Coll Cardiol Img 5:1191–1197. https://doi.org/10.1016/j.jcmg.2012.07.014

    Article  Google Scholar 

  36. Nikitin NP, Witte KKA, Thackray SDR, Goodge LJ, Clark AL, Cleland JGF (2003) Effect of age and sex on left atrial morphology and function. Eur J Echocardiogr 4:36–42. https://doi.org/10.1053/euje.2002.0611

    Article  CAS  PubMed  Google Scholar 

  37. Lang RM, Badano LP, Victor MA, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Retzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28:1-39.e14. https://doi.org/10.1016/j.echo.2014.10.003

    Article  PubMed  Google Scholar 

  38. Yuda S, Sato Y, Abe K, Kawamukai M, Kouzu H, Muranaka A, Kokubu N, Hashimoto A, Tsuchihashi K, Watanabe N, Miura T (2014) Inter-vendor variability of left ventricular volumes and strains determined by three-dimensional speckle tracking echocardiography. Echocardiography 31:597–604. https://doi.org/10.1111/echo.12432

    Article  PubMed  Google Scholar 

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Funding

Dr Georgiopoulos was supported by the Onassis Foundation under the special grant & support program for scholars’ association members (Grant No. R ZP 001/2019–2020) and by the European Association of Cardiovascular Imaging (Training Grant 2021). The other authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Author notes

  1. Stefano Figliozzi and Georgios Georgiopoulos have equal contribution as first author to this study.

Authors and Affiliations

  1. Clinical Echocardiography Diagnostic Service, Cardio Center, Humanitas Research Hospital IRCCS, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy

    Stefano Figliozzi, Renato Maria Bragato & Gianluigi Condorelli

  2. Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece

    Georgios Georgiopoulos, Alexandros Sianis & Ιoannis Petropoulos

  3. School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK

    Georgios Georgiopoulos

  4. Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

    Kostantinos Pateras

  5. Faculty of Public Health, University of Thessaly, Volos, Greece

    Kostantinos Pateras

  6. Cardiology Unit, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy

    Marco Previtero

  7. Multimodality Imaging Section IRCCS Policlinico San Donato, San Donato Milanese, Italy

    Lara Tondi

  8. King’s College Hospital, NHS Foundation Trust, London, UK

    Alexandros Papachristidis

  9. Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy

    Gianluigi Condorelli

  10. Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan

    Masaaki Takeuchi

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  1. Stefano Figliozzi
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Contributions

SF and GG are responsible of initial study conception and design. Material preparation, data collection and analysis were performed by SF, GG, KP and MT. The first draft of the manuscript was written by SF, GG and KP. All authors revised and implemented the manuscript critically for important intellectual content and approved the final manuscript.

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Correspondence to Stefano Figliozzi.

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Figliozzi, S., Georgiopoulos, G., Pateras, K. et al. Normal ranges of left atrial volumes and ejection fraction by 3D echocardiography in adults: a systematic review and meta-analysis. Int J Cardiovasc Imaging 38, 1329–1340 (2022). https://doi.org/10.1007/s10554-021-02520-9

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