European Heart Journal Advance Access published online on June 11, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm199
Left atrial remodelling in mitral regurgitation—methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam-computed tomographic study
1 Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
2 Cardiovascular Department, Hopital Bichat, 46 rue H Huchard, Paris 75018, France
3 Department of Radiology, Mayo Clinic, Rochester, MN, USA
4 Biomedical Imaging Resource Department, Mayo Clinic, Rochester, MN, USA
5 Department of Biomedical and Surgical Sciences, University of Verona, Italy
6 Section of Biostatistics, Mayo Clinic, Rochester, MN, USA
Received 27 February 2007; accepted 13 April 2007.
* Corresponding author. E-mail address: sarano.maurice{at}mayo.edu
Aims: To define accurate and normal range of echocardiographic left atrial (LA) volume measurement and to assess the prevalence, determinants, and outcome implications of LA enlargement in mitral regurgitation (MR).
Methods and results: We prospectively compared LA volume obtained simultaneously by electron beam-computed tomography (EBCT) and by four echocardiographic methods in 33 test patients. Accurate echocardiographic LA volume measurements were obtained only by biplane area–length method with vertical longitudinal-length (r = 0.95, P < 0.0001; 145 ± 57 vs. 143 ± 55 mL, P = 0.57). Using this method, the normal range in 100 normal subjects, the physiological determinants and outcome implications of LA enlargement in 320 patients with organic MR were analysed. In normal subjects, indexed to body surface area, LA index (27 ± 6 mL/m2) was not influenced by age or gender and values 
40 mL/m2 were beyond the upper limit of normal. In MR, the most powerful determinants of LA enlargement were higher regurgitant volume (RVol) and atrial fibrillation (AF) (P < 0.0001), followed by older age, female gender, higher left ventricular end-systolic volume, and mass (all P < 0.001). After diagnosis in sinus rhythm, LA index 40 mL/m2 predicted superiorly and independently to LA diameter the occurrence of AF [adjusted RR 1.48 (1.06–2.16), P < 0.01] and the combined endpoint of death or need for mitral surgery [adjusted RR 1.61 (1.3–2.0), P < 0.0001].
Conclusion: LA remodelling can be accurately assessed by echocardiography and LA index 40 mL/m2 is beyond the normal range. In organic MR, higher LA index is the combined result of multiple physiological effects, provides independent prognostic information, and therefore should be part of a comprehensive echocardiographic examination.
Key Words: Atrium • Echocardiography • Mitral valve • Computed tomography • Outcome
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