1 echo la workshop 2007 final3

Curriculum Vitae

IDI (Indonesian Medical Association)PAPDI (Indonesian Association of Internal Medicine)PERKI (Indonesian Heart Association)PUSKI (Indonesian Society of Medical Ultrasonography)PERKAVI (Indonesian Society of Heart Research)

AHA (American Heart Association – council on Cardiac Imaging)

ASFC (ASEAN Society & Federation of Cardiology)ISFC (International Society & Federation of Cardiology)WHL (World Hypertension League)ASE (American Society of Echocardiography)ASNC (American Society of Nuclear Cardiology)SCCT (Society of Cardiovascular Computed Tomography)

Membership :

National

International

Curriculum Vitae

Sept-Oct 1992 Nuclear Cardiology. Royal Adelaide Hospital. University of Adelaide. South Australia. Australia.

Nov 1992-February 1993 Nuclear Cardiology & Other Cardiac Imaging. Academische Zijkenhuijs Leiden. Netherland.

Jan 1995 Stress Echocardiography. Hunter-Hill Clinic Cardiology. Sydney. New South Wales. Australia.

April – June 2000 Research on Antioxidant Effect of Garlic Extract on Copper and Lypoxygenase-catalyzed oxidation of LDL. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. Germany.

Sept – Oct 2003 Research on the effect of Garlic Extract on Cholesterol Efflux from Lipid-loaded J-774 Macrophages. Institute of Biochemistry. University Clinic Charite. Humboldt University. Berlin. Germany.

Jan 2007 Advanced Course on Tissue Doppler Imaging. Chinese University. Hong Kong.

May 2007 Advanced Course (Level 2 Certification) on Cardiovascular Computed Tomography), Albany, New York, USA

Courses and Training :

Curriculum Vitae

1. Effects of Onion on Diabetic patients. 15th International Congress of Internal Medicine. Hamburg, (WEST GERMANY) : 18th - 22nd 1980.

2. Hypertension in the Critical Area of East Java. Singapore: 8th ASEAN Congress of Cardiology. 7-11 December 1990.

3. Blood glucose and other coronary risk factors in critical areas of East Java. Jakarta : 6th Congress of ASEAN Federation of Endocrinology, 2-4 July 1992.

4. The Effect of Garlic extracts (DDS, SAC) on Oxidized-LDL. Measurement of HETE, HODE and its isomeres by HPLC. 1st National,Congress of Indonesian Society of Heart Research. Jakarta : July 2002.

5. The Effect of Garlic extracts (DDS, SAC) on the Efflux of Cholesterol from Acetylated-LDL-loaded J-774 Macrophages. Asian Pacific Congress of Atherosclerosis. Nusadua, Bali 2004.

6. 3 Other International Publications 7. > 100 National Publications and Papers

Publications :

Echocardiographic Evaluation ofLeft Atrial Function

Budi Susetyo PikirDepartment of Cardiology & Vascular Medicine –

Faculty of MedicineDr.Soetomo Hospital – Airlangga University

SURABAYA

I. Reservoir during systole

II. Conduit during diastole

III. Active contraction during late diastole

Three Components of LEF ATRIAL FUNCTION

LA Volume-LA Pressure Relationship

LA Volume-LV Volume Relationship

S D

S D

LA Pressure-LA Volume-PV Velocity-TransMitral

Velocity

LA Pressure-LA Volume-Relationship

LV Remodelingand Dysfunction

↑ diastolic P or MR

LA remodeling

Atrial Fibrillation

Stroke/Death

A. LA size quantitation

1. LA & LAA dimension2. LA & LAA area

+ phasic LA area change by AQ technique3. LA & LAA volume• Maximal LA volume• Total volume of LA emptying• Passive LA Emptying Volume• Volume of LA emptying during active atrial

contraction

Echocardiographic Variables

Echocardiographic VariablesB. Indirectly derived LA variables

• LA ejection force• LA kinetic energy• Estimated LA dP/dtmax

C. Pulsed wave Doppler• Transmitral velocities at atrial contraction• Atrial reversal velocities at pulmonic vein• LAA Emptying Velocity

D. Tissue Doppler• Mitral annular velocity at atrial contraction• LA & LAA wall velocity

LA Dimension TTE 2-D & M-Mode

The Echo Manual. Oh, Seward, Tajik. 1999

A. LA size quantitation 1. LA dimension

Figure 1. To search M-mode tracing of left atrial appendage (LAA) (right), single M-mode beam guided by B-mode 2-chamber view (left) is directed immediately lateral to mitral annulus, trying to be perpendicular to both LAA walls. Detailed movement of LAA medial wall can be observed, thanks to high temporal resolution of M-mode technique and high axial resolution because of single M-mode beam direction, which is almost perpendicular to medial LAA wall.

de Luca I, Colonna P, Sorino M, et al. New Monodimensional Transthoracic Echocardiographic Sign of Left Atrial Appendage Function. J Am Soc Echocardiogr 2007;20:324-332.

A. LA size quantitation 1. LAA dimension, motion & function


Figure 2. Measurement of M-mode thickness before (Th1) and after (Th2) left atrial appendage (LAA) contraction. Thickening of medial LAA wall was computed as delta in millimeters (Δ), related to LAA contraction and relaxation phases. We subtracted value (as average of 5-7 consecutive measurements) at LAA relaxation phase to one at LAA contraction phase. Calculation of Δ: formula (Th2 − Th1).




Figure 3. Left, Pre-cardioversion (C) data (down normal Doppler transesophageal echocardiography [TEE] velocity, up presence of normal M-mode delta; in patients with atrial fibrillation posterior dip is observable as saw-tooth aspect with variable amplitude extent). Middle, Left atrial appendage (LAA) stunning 24 hours post-C (down low Doppler TEE velocity, up disappearance of M-mode delta). Right, LAA stunning recovery 7 days post-C (down recovery of Doppler TEE velocity, up recovery of M-mode delta; in patients with in sinus rhythm it is possible to detect contraction posterior dip with feature of beak, related to LAA function, after electrocardiographic P wave).




Figure 4. Scatterplot graphs of the measurements in the 88 patients, showing a good correlation (r = 0.76; p < 0.001) between the left atrial appendage (LAA) medial wall thickening indicated as “TTE DELTA M-MODE”, and the transesophageal LAA velocities, considered the gold standard for LAA function estimate.© 2007 American Society of Echocardiography




Blondheim DS , Osipov A, Meisel SR, Frimerman A, Shochat M, and Shotan A. Relation of Left Atrial Size to Function as Determined by Transesophageal Echocardiography Am J Cardiol 2005;96:457– 463.

LA Dimension TEE 2-D


Fig. 1. TTE parasternal short-axis view at level of aortic valve. Anteroposterior distance is represented by dashed line.

Fig. 2. TTE parasternal long-axis view at level of aortic valve. Anteroposterior length of left atrium is represented by dashed line.

Block M, Hourigan L, MD,.Bellows wH, Reeves J III,.Romson JL, et al. Comparison of left atrial dimensions by transesophageal and transthoracic echocardiography. J Am Soc Echocardiogr 2002;15:143-9

LA Dimension TTE 2-D


Fig. 3. TTE apical 4-chamber view at level of mitral annulus. Inferoposterior length of left atrium is represented by dashed line

Fig. 4. TTE apical 2-chamber view. Lateromedial length of left atrium is represented by dashed line




Fig. 5. TEE transverse mid-esophageal short-axis view at level of aortic valve with transducer rotated 30 to 60 degrees. Left atrial length is represented by dashed line

Fig. 6. TEE long-axis mid-esophageal view with transducer rotated 120 to 150 degrees. Left atrial length is represented by dashed line




Fig. 7. TEE mid-esophageal transverse 4-chamber view with 0-degree rotation. Left atrial length is represented by dashed line

Fig. 8. TEE mid-esophageal longitudinal 2-chamber view with transducer rotated to 90 degrees. Left atrial length is represented by dashed line




Figure 1. First 2-dimensional measure used M-mode method. Here, curser was placed perpendicular to left atrium in parasternal long axis view and diameter was measured using standard American Society of Echocardiography technique of leading edge to leading edge. Volumes were derived from cubed method, which assumes spheric shape

Jenkins C, Bricknell K, and Marwick TH. Use of Real-time Three-dimensional Echocardiography to Measure Left Atrial Volume: Comparison with Other Echocardiographic Techniques. J Am Soc Echocardiogr 2005;18: 991-997.

A. LA size quantitation 1. LA Volume by M-Mode, 2-D and 3-D

Figure 2. Two other methods were derived from apical 4- and 2-chamber views at ventricular end systole, which is marked by mitral valve closure. These were area-length method and Simpson’s method of disks

Jenkins C, Bricknell K, and Marwick TH. U.se of Real-time Three-dimensional Echocardiography to Measure Left Atrial Volume: Comparison with Other Echocardiographic Techniques. J Am Soc Echocardiogr 2005;18: 991-997.

A. LA size quantitation 2 & 3. LA Volume by M-Mode & 2-D and 3-D

Figure 3. Analysis of left atrial volume using 3-dimensional (3D) echocardiography. Selection of one image (top right), automated contour tracing (top left), superimposition of all contours in 3D space (bottom left), and 3D volume

Jenkins C, Bricknell K, and Marwick TH. U.se of Real-time Three-dimensional Echocardiography to Measure Left Atrial Volume: Comparison with Other Echocardiographic Techniques. J Am Soc Echocardiogr 2005;18: 991-997.

A. LA size quantitation 2 & 3. LA Volume by M-Mode, 2-D and 3-D

Volumes According to Phasic Changes

1. Maximum LA volume; volume just before MV opening2. Minimum LA volume; volume at MV closure


3-D & 2-D Echo

3. Total LA emptying volume (Reservoir volume) = maximum LA volume - minimum LA volume

4. LA passive emptying volume = maximal LA volume - pre-atrial contraction LA volume (at the onset of the P-wave on ECG)

5. LA active emptying (contractile) volume = LA stroke volume = pre-atrial contraction LA volume - minimum LA volume

6. LA (passive) conduit volume = LV stroke volume - the total LA emptying volume

7. LAEF = LA active emptying (contractile) volume / pre-atrial contraction LA volume

Total LA Emptying Volume

LV Stroke Volume

LA Stroke Volume

Figure 1. Schema of left atrial (LA) and left ventricular (LV) time-volume curve derived from real-time 3-dimensional echocardiography. LA passive emptying dV/dt and LV early diastolic dV/dt were determined as maximal slopes of time-volume curve of respective phases. LA active emptying fraction was determined as: [(precontraction LA volume − minimal LA volume)/(maximal LA volume − minimal LA volume)] × 100.

Shin MS, MD, Fukuda S, Song J-M et al. Relationship Between Left Atrial and Left Ventricular Function in Hypertrophic Cardiomyopathy: A Real-time 3-Dimensional Echocardiographic Study . J Am Soc Echocardiogr 2006; 19:796-801.

3-D & 2-D Echo


LA active emptying fraction was determined as : [(precontraction LA volume − minimal LA volume) / (maximal LA volume − minimal LA volume)] × 100.

Figure 1 (A) LAA volume measurement by 3DE using Simpson's rule. A slice of 3 mmthickness is measured in the long-axis plane of the LAA. (B) Contour tracing andlabeling of the slice in the short axis. After tracing and labeling, the volume of theentire LAA is displayed in the reference image and the end-diastolic (C) and endsystolic(D) volume is calculated.

Figure 2 The principle of left atrial appendage ejection fraction measurement usingtwo-dimensional area method. From the three-dimensional data set an end-diastolic(A) and end-systolic (B) long-axis view is used for percent area ejection fractioncalculation.

LAA diastole was measured at the onset of the ECG P-wave and LAA systole at the ECG R-wave.

Valocik G, Kamp O, Mihciokur M, Mannaerts HFJ, et al. Assessment of the Left Atrial Appendage Mechanical Function by Three Dimensional Echocardiography. Eur J Echocardiogr 2002;3:207-13.

Left Atrial Appendage FunctionEF by 3-D & 2-D Echo


Figure 5. Mean LAA emptying velocities (centimeters per second) in sinus rhythm before, immediately and 30 minutes following RFA of paroxysmal AFL demonstrating no effect due to the RF lesion itself. SR = sinus rhythm; vertical bars = mean ± SD.

Sparks PB, Jayaprakash S, Vohra JK, et al. Left Atrial “Stunning” Following Radiofrequency Catheter Ablation of Chronic Atrial Flutter. J Am Coll Cardiol 1998;32:468 –75)



Figure 3 Scatterplot of linear regression analysis of the left atrial appendage (LAA) volume ejection fraction (EFv) and area ejection fraction (EFa) versus LAA late diastolic peak emptying velocity (PEV).

Valocik G, Kamp O, Mihciokur M, Mannaerts HFJ, et al. Assessment of the Left Atrial Appendage Mechanical Function by Three Dimensional Echocardiography. Eur J Echocardiogr 2002;3:207-13.



B. Indirectly derived LA variables1. LA ejection force2. LA kinetic energy3. Estimated LA dP/dtmax

1. LA ejection force (kdyne) = 0.5 x 1.06 x mitral annulus area x (peak A velocity2)

2. LA kinetic energy (kerg) = 0.5 x 1.06 x LA stroke volume x (peak A velocity2)

JACC 1993, 22:221, AJC 1998, 82:1220

B. Indirectly derived LA variables1. LA ejection force2. LA kinetic energy3. Estimated LA dP/dtmax

Change of LA Function AfterSeptal Ablation in HCM

JACC 1999, 34:1123

Estimation of LA dP/dtmax byMitral Inflow and PV Flow

LA dP/dtmax = 0.1 M-AC (cm/s2) + 1.8 PV (cm/s) - 4.1JACC 1999, 34:795

3. Estimated LA dP/dtmax

C. Pulsed wave Doppler1. Transmitral velocities at atrial contraction2. Atrial reversal velocities at pulmonic vein3. LAA Orifice Velocities

Escudero EM, Mauro MS, and Laugle C. Bilateral Atrial Function After Chemical Cardioversion of Atrial Fibrillation with Amiodarone: An Echo-Doppler Study. J Am Soc Echocardiogr 1998;11:365-71.


Figure 1 Example of apical four-chamber view with pulsed-wave Doppler recording of mitral (top) and tricuspid (bottom) flows used to calculate left and right atrial mechanical functions. Mitral peak A velocity (34 cm/sec), mitral annulus diameter (2.8 cm), tricuspid peak A velocity (40 cm/sec), and tricuspid annulus diameter (2.9 cm) can be seen in this echo-Doppler study taken in one patient 24 hours after cardioversion with amiodarone.

Figure 2 A, Diagram of LAA flow in sinus rhythm. 1, LAA contraction; 2, LAA filling; 3, systolic reflection waves (positive and negative); 4, early diastolic LAA outflow (see text for details). B, Pulsed-Doppler tracing of LAA flow in sinus rhythm (flow signals 1 to 4 as in A).

Agmon V, Khandheria BK, Gentile F, and Seward, JB. Echocardiographic Assessment of the Left Atrial Appendage. (J Am Coll Cardiol 1999;34:1867–77)


Figure 5. A, Image of pulsed wave Doppler spectral flow pattern in left atrial appendage (LAA) demonstrating flow during 4 distinct periods: a, LAA contraction; b, LAA filling; c, systolic reflection waves (positive and negative); d, early diastolic LAA outflow, and

left coronary artery (B). Continuous flow on one side of baseline with low-velocity systolic (S) and diastolic (D) phase with early peak followed by gradual deceleration.


Figure 1 Pathologic specimens of the LAA displaying its complex and extremely variable configuration, thus emphasizing the need for routine meticulous echocardiographic scanning of the appendage in multiple planes. A, Bilobed LAA (LAA is on right side of picture). B, Single-lobed LAA with an additional "appendix" at its distal end (outside the plane of main LAA body). C, Multilobed LAA (multiple small lobes). D, Multiplane transesophageal echocardiographic demonstration of a multilobed LAA (90° and 135° scanning in D-1 and D-2, respectively). The orifice of the LAA (LA–LAA junction) is marked by a pair of arrows in A to C. (A to C, Courtesy of Dr. W. B. Edwards, Department of Anatomic Pathology, Mayo Clinic.)

Agmon V, Khandheria BK, Gentile F, and Seward, JB. Echocardiographic Assessment of the Left Atrial Appendage. J Am Coll Cardiol 1999;34:1867–77.



Figure 3 A, Pulsed-Doppler tracing of LAA flow in AF. Note the rapid fibrillatory flow waves, which are of higher velocity during ventricular diastole than systole (arrows; see text for details). B, Pulsed-Doppler tracing of LAA flow in AFL (with a 2:1 ventricular response). Flutter flow waves are, in general, slower and of higher velocity than fibrillatory flow waves.

Agmon V, Khandheria BK, Gentile F, and Seward, JB. Echocardiographic Assessment of the Left Atrial Appendage. (J Am Coll Cardiol 1999;34:1867–77)

Agmon Y, Khandheria B, Meissner I, et al. Are Left Atrial Appendage Flow Velocities Adequate Surrogates of Global Left Atrial Function? A Population-Based Transthoracic and Transesophageal Echocardiographic Study J Am Soc Echocardiogr 2002;15: 433-40.)

Figure 1A, TEE view (45 degree) of LAA.LAA flow is measured with pulsed wave Doppler, with a sample volumeplaced in proximity to the appendage orifice (double arrow, diameter of appendage orifice). B, Typical LAA flow in sinus rhythm. Late diastolic appendage outflow velocities following electrocardiographicPwave (arrow) are related to appendage contraction. LAA, Left atrial appendage.


Figure 2. Doppler flow envelopes of LAA velocities (centimeters per second) in chronic AFL (top), in sinus rhythm immediately following AFL termination (middle) and in sinus rhythm at the 3 week follow-up assessment (bottom). Vertical axis scale (centimeters per second).© 1998 American College of Cardiology

chronic AFL

sinus rhythm immediately following AFL termination

3 week follow-up assessment

(Atrial Stunning)



Figure 1. Mean LAA emptying velocities (centimeters per second) in AFL and in sinus rhythm immediately, 30 minutes and 3 weeks following RFA of chronic AFL. SR = sinus rhythm; vertical bars = mean ± SD.



Figure 4. Mean mitral in-flow A-wave velocities (centimeters per second) in sinus rhythm immediately, 30 minutes and 3 weeks following RFA of chronic AFL. SR = sinus rhythm; vertical bars = mean ± SD.



Effect Beta-Blockade on LAA Function

Figure 1 Transesophageal pulsed Doppler recording of the left atrial appendage (LAA) flow velocity pattern in one patient with chronic atrial fibrillation at baseline (A) and at 10 minutes after intravenous bolus of metoprolol (B). After intravenous bolus of metoprolol, LAA emptying velocity decreased from 11 cm/s to 8 cm/s.

Mehmet Bilge, MD, Niyazi Güler, MD, Beyhan Eryonucu, MD, and Reha Erkoç,. Does Acute-Phase Beta Blockade Reduce Left Atrial Appendage Function in Patients with Chronic Nonvalvular Atrial Fibrillation? J Am Soc Echocardiogr 2001;14:194-9.


Effect Beta-Blockade on LAA Function

Mehmet Bilge, MD, Niyazi Güler, MD, Beyhan Eryonucu, MD, and Reha Erkoç,. Does Acute-Phase Beta Blockade Reduce Left Atrial Appendage Function in Patients with Chronic Nonvalvular Atrial Fibrillation? J Am Soc Echocardiogr 2001;14:194-9.

Figure 2 Transesophageal 2-dimensional images of left atrial appendage at baseline (A) and after 7 days of metoprolol (B) in the same patient as in Figure 1. Note that after 7 days of metoprolol, new thrombus (THR) developed in the left atrial appendage. SEC, Spontaneous echo contrast.


Figure 1 Left atrial appendage thrombus seen in case 1.

Figure 2 Severely reduced left atrial appendage emptyingvelocity seen in case 1.

Kamalesh M, Copeland TB, and Sawada S. Severely Reduced Left Atrial Appendage Function: A Cause of Embolic Stroke in Patients in Sinus Rhythm ? J Am Soc Echocardiogr 1998;11:902-4.

Left Atrial Appendage FunctionLAAev (LAA emptying velocity) by Pulsed Doppler


Table 1 Comparison of LAAEVGroup 1SR with stroke(n 5 2)

Group 2AF(n 5 6)

Group 3SR no stroke(n 5 14)

LAAEV (m/s) Mean 61 SD

0.38 ± 6 0.02 0.28 ± 6 0.05 1.07 ± 6 0.26

SR, Sinus rhythm; AF, atrial fibrillation; LAAEV, left atrial appendage emptying velocity. Paired t test: Group 1/Group 2, P 5 NS; Group 1/Group 3, P , .001.

Kamalesh M, Copeland TB, and Sawada S. Severely Reduced Left Atrial Appendage Function: A Cause of Embolic Stroke in Patients in Sinus Rhythm ? J Am Soc Echocardiogr 1998;11:902-4.

LAAev (LAA emptying velocity) by Pulsed Doppler


Fig. 1. Two-dimensional echocardiogram of left atrial appendage demonstrating membrane at orifice (arrows ). LA, Left atrium; LAA, left atrial appendage.

Fig. 2. Color Doppler demonstrating narrowed orifice of left atrial appendage. LA , Left atrium; LAA , left atrial appendage.

Coughlan B, Lang RM, and Spencer KT. Left Atrial Appendage Stenosis. J Am Soc Echocardiogr 1999;12:882-3.

Orifice LAA Stenosis due to Membran Structure PRIMARY LAA DISEASES

Fig. 3. Doppler echocardiography demonstrating elevated peak forward velocity across left atrial appendage opening (small arrow ) during atrial contraction after electrocardiographic P wave (arrow ).© 1999 American Society of Echocardiography

Coughlan B, Lang RM, and Spencer KT. Left Atrial Appendage Stenosis. J Am Soc Echocardiogr 1999;12:882-3.

Orifice LAA Stenosis due to Membran Structure

Fig. 1. (Top) Linear membrane in body of left atrial appendage (arrows). Spontaneous echocardiographic contrast is present in left atrium (LA) and left atrial appendage (LAA). LV, left ventricle. (Bottom) Pulsed wave Doppler spectral profile showing flow velocities across region of LAA membrane. Patient is in atrial fibrillation. Sawtooth pattern with peak ejection velocities within normal expected range is found.© 2002 American Society of Echocardiography

Fig. 2. Specimen obtained at surgery. Thin, linear, membranous structure (arrows) is demonstrated.© 2002 American Society of Echocardiography

Bakris N, Tighe DA, Rousou JA et al. Nonobstructive Membranes of the Left Atrial Appendage Cavity: Report of Three Cases. ( Am Soc Echocardiogr 2002;15:267-70.


Fig. 3. Transesophageal echocardiographic (TEE) images obtained in multiple planes (A and B) demonstrating thin, linear, membranous structure (arrows) crossing body of left atrial appendage (LAA). LA, left atrium.© 2002 American Society of Echocardiography

Fig. 4. (Top) Linear membrane crossing body of left atrial (LAA) appendage (arrows). Spontaneous echocardiographic contrast is present in left atrium (LA). (Bottom) Pulsed wave Doppler spectral profile showing flow velocities across region of LAA membrane. Patient is in sinus rhythm. Peak ejection velocities within normal expected range are demonstrated.

Bakris N, Tighe DA, Rousou JA et al. Nonobstructive Membranes of the Left Atrial Appendage Cavity: Report of Three Cases. ( Am Soc Echocardiogr 2002;15:267-70.


D. Tissue Doppler1. Mitral annular velocity at atrial contraction2. LA wall velocity3. LAA wall velocity

LA Systolic Function Evaluation

by A’ at Mitral Annulus

JASE 2004, 17: 353


LA Systolic Function Evaluationby A’ at Mitral Annulus

JASE 2004, 17: 353


LA Systolic Function Evaluation by A’ at Mitral Annulus

JASE 2004, 17: 353


Effect of Afterload Reduction on LAA

function.

Bauer F, Verdonck A, Schuster I, et al. Left Atrial Appendage Function Analyzed by Tissue Doppler Imaging in Mitral Stenosis: Effect of Afterload Reduction after Mitral Valve Commissurotomy. JASE 2005, 18:934

Figure 1. Stop frame of spectral tissue Doppler velocities recorded on the LAA.


Effect of Afterload Reductionon LAA function

JASE 2005, 18:934

Mitral Inflow

LAA flow

LAA Tissue Velocity

Pre PMV Post PMV

Effect of Afterload Reduction on LAA function

JASE 2005, 18:934


Figure 1. Measurement of left atrial (LA) wall contraction velocity during atrial contraction (LAWV) by tissue Doppler echocardiography. Region of interest for measuring LAWV was placed at posterobasal wall of LA on apical 2-chamber view. Positive peak wave obtained during atrial contraction phase is considered as LAWV

Yoshida N, Okamoto M, and Beppu S. Validation of Transthoracic Tissue Doppler Assessment of Left Atrial Appendage Function. J Am Soc Echocardiogr 2007;20:521-526.


Figure 2. Left atrial (LA) wall contraction velocity during atrial contraction (LAWV) obtained at 3 sampling sites of posterior LA wall. Positive peak obtained during atrial contraction (LAWV) does not considerably change among sampling sites (red, blue, and yellow lines). This may indicate that ultrasonic beam from apical approach is almost parallel to direction of LA wall motion during atrial contraction. ROI, Region of interest




Figure 3. Left atrial (LA) wall contraction velocity during atrial contraction (LAWV) plotted against LA appendage flow velocity (LAAV) in patients with paroxysmal atrial fibrillation


Atrial Index

LAEF by TEE= (LA max area – LA min area)/LA max area X 100

Atrial Index= Transmitral VTI x LAEF / LA max area

AHJ 2002, 143:181

Atrial Index

AHJ 2002, 143:181

Univariate Analysis

Multivariate Analysis

Inaba Y, Yuda S, Kobayashi N, et al. Strain Rate Imaging for Noninvasive Functional Quantification of the Left Atrium: Comparative Studies in Controls and Patients With Atrial Fibrillation. J Am Soc Echocardiogr 2005;18:729–736.

Figure 1 Illustration of SR-LA calculation. SR can be calculated from 2 velocity measurements—(v (r), v (r r)—whose sample volume distance is r using TDI. LV, left ventricle. Figure 2 A representative SR-LA curve with

measurements of SR-LAs, SR-LAe, and SR-LAa in a control subject.


Inaba Y, Yuda S, Kobayashi N, et al. Strain Rate Imaging for Noninvasive Functional Quantification of the Left Atrium: Comparative Studies in Controls and Patients With Atrial Fibrillation. J Am Soc Echocardiogr 2005;18:729–736.


Figure 3 Representative SR-LA curves with measurements of SR-LAs, SR-LAe, and SR-LAa in a control subject (A), a patient with paroxysmal atrial fibrillation (AF) (B), and a patient with persistent AF (C).

Donal E, Raud-Raynier P, Racaud A, et al. Quantitative Regional Analysis of Left Atrial Function by Doppler Tissue Imaging–derivedParameters Discriminates Patients with Posterior and Anterior Myocardial Infarction. J Am Soc Echocardiogr 2005;18:32–8.)


Figure 1 Example of a Doppler tissue imaging curve analysis. Region of interest (ROI) was manuallypositioned as used for study in the left atrial septal and lateral walls.A, Peak velocity in end diastole; E, peakvelocity in early diastole; IVC, peak velocity recorded at time of isovolumic contraction; IVR, peak velocityrecorded in isovolumic relaxation time; S, peak velocity recorded in systole.

Figure 2 Example of tissue tracking curves displayed on software. Peak systolic displacement (S) of sametwo regions of interest described in Figure 1 could be readily calculated.

Figure 3 Example of strain analysis; we were able to record degree of systolic shortening or lengtheningof two regions of interest studied.

SUMMARY1. LA Dysfunction was mostly due to LV

Dysfunction or Other Abnormalities (MS, etc.)

2. AF was the final result of LA Remodelling & Dysfunction

3. LA Volume was more accurate to predict morbidity & mortality compared to LA Dimension

SUMMARY4. TVI and its derivative of LA wall may be used

to assess LA function & LV Abnormality.5. Pulsed-Doppler as well as TVI of LAA were

usefull to assess LAA function.

THANK YOU

Figure 2. Parasternal short-axis view demonstrating apparent thrombus in left coronary artery (LCA) (A) and true LCA in same patient (B). Ao, Aorta; PA, pulmonary artery.

Ramaswamy P, Lytrivi ID, Srivastava S, et al. Left Atrial Appendage: Variations in Morphology and Position Causing Pitfalls in Pediatric Echocardiographic Diagnosis. J Am Soc Echocardiogr 2007; 20:1011-1016.

Left Atrial AppendageVariation in Morphology & Position

Figure 1 Anatomy of left atrial appendage (LAA). Circ, Circumflex coronary artery; LAD, left anterior descending coronary artery; LCA, left coronary artery; LV, left ventricle; MPA, main pulmonary artery.

Figure 3. Parasternal short-axis view demonstrating apparent coronary artery aneurysm (A) and normal left coronary artery (LCA) with branching in same patient (B). Ao, Aorta; Circ, circumflex coronary artery; LA, left atrium; LAD, left anterior descending coronary artery; PA, pulmonary artery.



Figure 4. Parasternal short-axis view tilted superiorly to demonstrate origin of coronary aneurysm is actually left atrial (LA) appendage arising from LA. Ao, Aorta; PA, pulmonary artery.

Ramaswamy P, Lytrivi ID, Srivastava S, et al. Left Atrial Appendage: Variations inMorphology and Position Causing Pitfalls in Pediatric Echocardiographic Diagnosis. J Am Soc Echocardiogr 2007; 20:1011-1016.


Figure 6. Intraoperative midesophageal 2-chamber view demonstrating inverted left atrial (LA) appendage mimicking thrombus. LPV, Left upper pulmonary vein; LV, left ventricle.



Figure 7. A, Parasternal short-axis image in patient with tetralogy of Fallot with pulmonary atresia demonstrating possible misdiagnosis of tip of left atrial (LA) appendage (LAA) as atretic pulmonic valve (PV) and body of LAA as main pulmonary artery (MPA). B, Confirmation that atretic PV and MPA are actually LAA filling space normally occupied by MPA. C, Pulsed wave Doppler flow in LAA with typical back and forth low-velocity flow. Ao, Aorta.



Figure 8. Modified subcostal sagittal view demonstrating orifice of left atrial (LA) appendage (LAA) (A), stenotic jet at orifice of LAA by color flow mapping (B), and continuous wave Doppler across orifice of LAA with peak velocity of 3.33 m/s during LAA contraction or “a” wave (C). Ao, Aorta.


Figure . Measurement of time interval from the onset of P wave on surface ECG to the beginning of A wave (PA) interval with tissue Doppler Echocardiography.

Özer N, Yavuz B, Can I, et al. Doppler Tissue Evaluation of Intra-atrial and Interatrial Electromechanical Delay and Comparison with P-wave Dispersion in Patients with Mitral Stenosis. J Am Soc Echocardiogr 2005;18:945-948.


Merckx KL, MD, De Vos CB, Palmans A, Habets J, BSc, e al. Atrial Activation Time Determined by Transthoracic Doppler Tissue Imaging Can Be Used as an Estimate of the Total Duration of Atrial Electrical Activation. J Am Soc Echocardiogr 2005;18:940-944

Figure 1. Example of measurement of time from initiation of electrocardiographic P wave (lead II) to peak of local lateral left atrial Doppler tissue signal.

Left Atrial AppendageAtrial Activation Time

Figure 2. Correlation between signal-averaged electrocardiogram (ECG) and P-wave duration on surface ECG (A), time from onset of ECG P wave (lead II) until onset of A wave as determined by flow Doppler echocardiography over mitral valve (B), and time from initiation of ECG P wave (lead II) to peak of local lateral left atrial Doppler tissue signal (C). Open circles, Patients with history of atrial fibrillation

Merckx KL, MD, De Vos CB, Palmans A, Habets J, BSc, e al. Atrial Activation Time Determined by Transthoracic Doppler Tissue Imaging Can Be Used as an Estimate of the Total Duration of Atrial Electrical Activation. J Am Soc Echocardiogr 2005;18:940-944

Left Atrial AppendageAtrial Activation Time

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