Real three-dimensional assessment of left atrial and left atrial appendage volumes by 64-slice spiral computed tomography in individuals with or without cardiovascular disease

doi:10.1016/j.ijcard.2008.11.055

International Journal of Cardiology

Volume 140, Issue 2, 15 April 2010, Pages 189-196

https://doi.org/10.1016/j.ijcard.2008.11.055 Get rights and content

Abstract

Context

Left atrial (LA) volume is a prognosis factor of cardiovascular morbidity in patients with cardiovascular disease (CD). Recent developments of multislice computed tomography (MSCT) have made non invasive coronary angiography reliable for selected patients and new software facilitates truly volume measurements without geometrical assumptions.

Objective

To define, by using MSCT, LA and left atrial appendage (LAA) volumes in patients with or without CD.

Methods and results

In the population of patients referred to our laboratory for a conventional MSCT coronary angiography, 40 individuals without CD (Normal group) and 80 patients with CD (CD group) were prospectively selected. The CD group was constituted from 4 subgroups of patients with either coronary artery disease (n = 20), idiopathic dilated cardiomyopathy (n = 20), left ventricular hypertrophy (n = 20) or severe mitral regurgitation (MR group, n = 20). LAA and LA volumes were measured on a commercially available workstation. LA maximal and minimal volumes were lower in Normal group than in CD group, as LA ejection fraction (54 ± 10 versus 67 ± 20 ml/m², p < 0.0001; 31 ± 8 versus 46 ± 20 ml/m², p < 0.0001; 43 ± 8% versus 33 ± 14%, p < 0.001). LAA volume was larger in MR group than in Normal group (15 ± 7 ml versus 9 ± 3 ml, p < 0.0001).

Conclusion

This MSCT study provides normal values of LA and LAA volumes for patients who underwent MSCT coronary angiography and suggests that MSCT is helpful to assess the changes of LA volumes related to various CD.

Introduction

Left atrial (LA) size has been shown to be a marker of diastolic dysfunction and is related to cardiovascular morbidity in various cardiovascular diseases (CD) [1], [2], [3], [4], [5], [6]. An alteration in LA size may imply the progression of cardiac disease and LA volume appears as a more robust marker of adverse events than LA diameter or area [7]. Left atrial enlargement is usually measured using M-mode or bi-dimensional trans-thoracic echocardiography (TTE) [1], [8], [9]. The association of multislice computed tomography (MSCT) imaging and new 3D reconstruction software, allows direct left atrial or ventricular volume measurements without geometrical assumptions [10], [11], [12], [13], [14]. In the present study the maximal (LAmax) and minimal (LAmin) LA volume during the cardiac cycle, and the left atrial appendage volume (LAA), were obtained by MSCT in patients without cardiovascular disease and in patients with either severe mitral regurgitation (MR), coronary artery disease (CAD), left ventricular hypertrophy (LVH) or idiopathic dilated cardiomyopathy (DCM).

Section snippets

Study design and population

We have prospectively selected individuals from a cohort of patients scheduled for have a non-invasive coronary imaging using an ECG-gated 64-MSCT scanner between February 1, 2006 and March 30, 2007 in our Institution. The indication and the realization of MSCT imaging were in acceptance with the Institutional guidelines. MSCT exclusion criteria included age < 18 years, allergy to iodinated contrast, renal insufficiency (serum creatinine > 1.5 mg/dl), pregnancy, irregular heart rate, calcium score

Statistical analysis

Statistical analysis was performed using the Statview V.5 software (SAS Institute, Cary, NC, USA). Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were reported as percentages. Continuous data were compared between “Normal” and other groups using Mann–Whitney test. Categorical data were compared between groups using the chi-square test. Univariate associations of continuous clinical variables and MSCT variables were calculated using Spearman

Results

Three-dimensional reconstruction of LA and LAA is shown in Fig. 1. The post processing time for LA and LAA volumes measurements was 16 ± 4 min.

Discussion

This study has 3 major findings. First, this study showed feasibility of MSCT imaging with cardiac cycle gating and commercially available 3D reconstruction software in the detection of cyclic changes in LA and LAA volumes. Measurements were performed from a standardized coronary computed tomographic angiography protocol, without additional injection or radiation exposure. Second, the normal MSCT values for LAmax, LAmin, LAEF, LAEV, LAAmax and LAAmin, including the upper limits of normal were

Study limitations

Our study has some limitations. The sample size limitations may have precluded discerning small differences in LA volume and function between patients with or without cardiovascular disease and in the different subgroups of patients. Because of the radiation exposure, the inclusion of normal volunteers to constitute the Normal group was not possible. Thus, we have carefully selected individuals without history of cardiovascular disease and with normal transthoracic echocardiography for the

Conclusion

Our results underline that maximal and cyclic changes of left atrial and left atrial appendage volumes might be evaluated from the dataset of conventional contrast enhanced MSCT coronary angiography with cardiac gating. The left atrial anatomic differences between individuals with or without cardiovascular disease in normal sinus rhythm might be also assessed, without additional contrast media infusion or radiation exposure. These measurements have to be taken into account to improve the risk

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [41].

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2019, Computers in Biology and Medicine
Percutaneous left atrial appendage (LAA) closure (placement of an occluder to close the appendage) is a novel procedure for stroke prevention in patients suffering from atrial fibrillation. The closure procedure planning requires accurate LAA measurements which can be obtained from computed tomography (CT) images.
We propose a novel semi-automatic LAA segmentation method from 3D coronary CT angiography (CCTA) images. The method segments the LAA, proposes the location for the occluder placement (a delineation plane between the left atrium and LAA) and calculates measurements needed for closure procedure planning. The method requires only two inputs from the user: a threshold value and a single seed point inside the LAA. Proposed location of the delineation plane can be intuitively corrected if necessary. Measurements are calculated from the segmented LAA according to the final delineation plane.
Performance of the proposed method is validated on 17 CCTA images, manually segmented by two medical doctors. We achieve the average dice coefficient overlap of 92.52% and 91.63% against the ground truth segmentations. The average dice coefficient overlap between the two ground truth segmentations is 92.66%. Our proposed LAA orifice localization is evaluated against the desired location of the LAA orifice determined by the expert. The average distance between our proposed location and the desired location is 2.51 mm.
Segmentation results show high correspondence to the ground truth segmentations. The occluder placement method shows high accuracy which indicates potential in clinical procedure planning.
Left atrial volume assessed by ECG-gated computed tomography: Variations according to age, gender and time during the cardiac cycle
2018, Diagnostic and Interventional Imaging
Citation Excerpt :
We did not compare our CT measurements to MRI. However, this work has been already done; at the 40% period of the RR cycle, normal value varies between 54 ± 10 mL/m2 [13], study done using CT) and 50 ± 6 mL/m2 [14], study done using MRI). These results are similar to ours and show that MDCT can be as accurate as MRI to estimate cardiac volume as previously demonstrated [15].
The purpose of this study was to retrospectively assess the accuracy of the maximal left atrial volume (LAV_max) measured at 75% of the cardiac cycle compared to the 40% measurements and to evaluate this volume according to age and gender.
A total of 150 patients with a mean age of 50 ± 17 (SD) years (range: 21–79 years) were analyzed. There were 78 men and 72 women. LAV_max were measured from retrospective triphasic cardiac-gated multi-detector computed tomography (MDCT) data at the 40% (LAV₄₀) and 75% (LAV₇₅) of the RR cycle phases by a semi-automatic method.
LAV₄₀was 50.7 ± 14 mL/m² and LAV₇₅ was 42.5 ± 13 mL/m². The difference was statistically significant. Considering the reference range of LAV_max reported in the literature, 33% of the patients had enlarged LA with LAV₄₀ and only 17% with LAV₇₅. These volumes were positively influenced by age but not by gender. The relationship between LAV₇₅ and LAV₄₀ was: LAV₇₅ = 0.908 LAV₄₀ – 3.486 (r² = 0.92) or LAV₄₀ = 1.1 × LAV₇₅ + 3.8 (r² = 0.92).
LAV_max measured at the 75% of the cardiac cycle phase significantly underestimates actual LAV leading to reconsider normal values. LAV₄₀ can be computed from the measured value of LAV₇₅ obtained on prospective ECG-gated MDCT.
Mitral Annular Dimensions and Geometry in Patients with Functional Mitral Regurgitation and Mitral Valve Prolapse Implications for Transcatheter Mitral Valve Implantation
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The aims of this study were to determine D-shaped mitral annulus (MA) dimensions in control subjects without significant cardiac disease and in patients with moderate to severe mitral regurgitation (MR) being considered for transcatheter mitral therapy and to determine predictors of annular size, using cardiac computed tomography.
The recently introduced D-shaped method of MA segmentation represents a biomechanically appropriate approach for annular sizing prior to transcatheter mitral valve implantation.
Patients who had retrospectively gated cardiac computed tomography performed at our institution (2012 to 2014) and were free of significant cardiac disease were included as controls (n = 88; 56 ± 11 years of age; 47% female) and were compared with patients with moderate or severe MR due to functional mitral regurgitation (FMR) (n = 27) or mitral valve prolapse (MVP) (n = 32). MA dimensions (projected area, perimeter, intercommissural, and septal-to-lateral distance), maximal left atrial (LA) volumes, and phasic left ventricular volumes were measured.
MA dimensions were larger in patients with FMR or MVP compared with controls (area index 4.7 ± 0.6 cm²/m², 6.0 ± 1.3 cm²/m², and 7.3 ± 1.7 cm²/m²; perimeter index 59 ± 5 mm/m², 67 ± 9 mm/m², and 75 ± 10 mm/m²; intercommissural distance index 20.2 ± 1.9 mm/m², 21.2 ± 3.1 mm/m², and 24.7 ± 3.2 mm/m²; septal-to-lateral distance index 14.8 ± 1.6, 18.1 ± 3.3, and 19.5 ± 3.4 mm/m² in controls and patients with FMR and MVP, respectively; p < 0.05 between controls and MR subgroups). Absolute MA area was 18% larger in patients with MVP than patients with FMR (13.0 ± 2.9 cm² vs. 11.0 ± 2.3 cm²; p = 0.006). Although LA and left ventricular volumes were both independently associated with MA area index in controls and patients with MVP, only LA volume was associated with annular size in patients with FMR.
Moderate to severe MR was associated with increased MA dimensions, especially among patients with MVP compared with control subjects without cardiac disease. Moreover, unlike in controls and patients with MVP, annular enlargement in FMR was more closely associated with LA dilation.
Right ventricular dysfunction and dilatation in patients with mitral regurgitation: Analysis using ECG-gated multidetector row computed tomography
2013, International Journal of Cardiology
Citation Excerpt :
Advances in sixty-four slice multidetector row CT (64-MDCT) technology have increased the feasibility of noninvasive coronary angiography and the comprehensive evaluation of cardiac function and anatomic characteristics with high temporal resolution using a multisector reconstruction algorithm [8,9]. Sixty-four to 320 slice computed tomography may assist in the evaluation of atrial volume and function index [10–14]. Furthermore, 16- and 64-MDCT scans accurately assess valvular diseases and function using the same data set that is acquired for the evaluation of coronary arteries [15,16].
This study prospectively compared the accuracy of a sixty-four slice multidetector row CT (64-MDCT) in cardiac magnetic resonance imaging (MRI) for the assessment of right ventricular (RV) dysfunction and dilatation in patients with mitral regurgitation.
Eighty-four patients underwent ECG-gated 64-MDCT for the assessment of RV dysfunction and dilatation; 54 of these patients had known mitral regurgitation. End-diastolic and end-systolic volumes, stroke volume, and ejection fraction were measured using the 64-MDCT, and these results were retrospectively compared to the results of MRI (reference standard). Agreement between the 64-MDCT and MRI results was investigated using linear regression and Bland–Altman analyses. Receiver operating characteristic analyses calculated the sensitivity and specificity of RV dilatation on 64-MDCT scans for the prediction of mitral regurgitation severity and dysfunction, respectively.
No significant differences in RV function parameters were calculated between 64-MDCT and MRI (r = 0.87 to 0.94; all p < 0.001). Good intertechnique agreement was obtained using linear regression and Bland–Altman analyses. ROC analyses revealed that RV enlargement (> 33 mm) on 64-MDCT scans predicted the RV dysfunction of mitral regurgitation with a sensitivity of 92.9% and a specificity of 82.9%.
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Assessment of the structural remodeling of the left atrium by 64-multislice cardiac CT: Comparative studies in controls and patients with atrial fibrillation
2012, International Journal of Cardiology
Citation Excerpt :
In addition, the function of the LA is attracting a great deal of interest in these patients because the volume and function of the LA are known to be independent parameters that can predict the success of RFA [9]. Previous studies have generally assessed the function of the left atrial proper or the left atrial appendage (LAA) separately [10–13]. Recently, LA volume quantification with cardiac MDCT has been challenged in controls and AF patients, and a few recent reports have demonstrated a close correlation between cardiac CT and echocardiography [11,14–16].
To assess the functional differences among the three anatomic compartments of the left atrium (LA) using 64-multislice cardiac CT in controls and patients with atrial fibrillation (AF).
We examined 144 individuals (105 males, mean age 56.42 ± 12.04 years) undergoing 64-multislice cardiac CT and divided them into 48 control, 53 paroxysmal AF (PAF), and 43 persistent AF (PeAF) patients. The LA was divided into three anatomic compartments according to their embryologic origins: venous LA (VLA), anterior LA (ALA), and LA appendage (LAA). Each volume was calculated using a threshold-based, three-dimensional segmentation. The LA parameters were defined as maximum and minimum LA volume indices, emptying volume, and ejection fraction. We compared the LA parameters of each compartment in controls, PAF patients, and PeAF patients.
In each of the three LA compartments, the maximum LA volume index was lowest in controls (LAA, 4.8 ml/m²; VLA, 18.3 ml/m²; ALA, 37.1 ml/m²) and highest in PeAF patients (LAA, 9.8 ml/m²; VLA, 30.0 ml/m²; ALA, 67.3 ml/m²). Regarding the three LA compartments, the ejection fraction was highest in the LAA and lowest in the VLA in controls (LAA, 58.3%; VLA, 29.0%; ALA, 47.4%) and in PAF patients (LAA, 47.3%; VLA, 18.3%; ALA, 39.2%). In PeAF patients, the emptying volumes and ejection fractions of the VLA were approximately zero.
The anatomic compartments of the LA play different roles in AF patients. The LAA has both highest contractility and independent function, and the VLA is the most severely affected by LA dysfunction. Our results may be helpful in understanding the pathophysiology of AF and predicting treatment responses to radiofrequency ablation in the future.
Low dose 320-row CT for left atrium and pulmonary veins imaging - The feasibility study
2012, European Journal of Radiology
To evaluate the feasibility of low dose target-CTA volume scan for left atrium and pulmonary veins imaging using 320-row CT.
Forty-two patients (females 12, males 30; mean age 55.2 years; mean body mass index (BMI) 25.7 kg/m²) with persistent or intermittent atrial fibrillation before catheter ablation were enrolled in this study. Scan protocol was target-CTA volume scan under prospective ECG-gating. The target of the exposure was only set at 40% of the R–R interval (which was at the left atrium maximal volume). The exposure time was minimal setting (350 ms). Tube voltage 100 kV (BMI ≤ 25 kg/m²) or 120 kV (BMI > 25 kg/m²), tube current 350–420 mA, and field of view of 180 mm × 180 mm–200 mm × 200 mm were used. The scanning range was from the level of the tracheal bifurcation to the diaphragm, and enabled to cover the left atrium and central pulmonary veins (120–140 mm). All of patients were divided into two groups according kV setting (100 kV and 120 kV). The image quality (good, moderate and poor) was evaluated by two reviewers. The CT-attenuation, image noise and contrast to noise ratio (CNR) of left atrium and every pulmonary vein branch were evaluated, respectively. The effective dose (ED) was calculated using a conversion coefficient for the chest 0.017.
Of 42 patients, the image quality was good in 26 cases (62%) and moderate in 16 cases (38%). There was no statistical difference in the CT-attenuation and CNR of left atrium and central pulmonary veins between the two groups (P > 0.05). The mean ED was 1.90 ± 0.19 mSv (range 1.57–2.25 mSv) in 100 kV group, and 3.83 ± 0.31 mSv (range 3.39–4.54 mSv) in 120 kV group.
The low dose target-CTA volume scan is feasible in pulmonary veins and left atrium imaging using 320-row CT. Slim patients can be scanned at 100 kV setting without loss of image quality.

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Real three-dimensional assessment of left atrial and left atrial appendage volumes by 64-slice spiral computed tomography in individuals with or without cardiovascular disease

Abstract

Context

Objective

Methods and results

Conclusion

Introduction

Section snippets

Study design and population

Statistical analysis

Results

Discussion

Study limitations

Conclusion

Acknowledgement

Mayo Clinic Proc

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Int J Cardiol

Int J Cardiol

J Am Coll Cardiol

Chest

Am Heart J

Am J Cardiol

Heart Rhythm

J Am Coll Cardiol

Acad Radiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol