This Article


Creative Commons License
Except where otherwise noted, this work is licensed under Creative Commons Attribution-NonCommercial 4.0 International License.

Strain Evaluation of Left Atrial Function: Ready for the Future?

Biagio Castaldi, MD 1, * ; and Ornella Milanesi, MD 1
1 Pediatric Cardiology Unit, University of Padua, Padua Italy
*Corresponding author: Biagio Castaldi, MD, Pediatric Cardiology Unit, University of Padua, Padua Italy. Tel: +39-3288970999, Fax: +39-0498218089, E-mail:
Archives of Cardiovascular Imaging. 2014 May; 2(2): e19584 , DOI: 10.5812/acvi.19584
Article Type: Letter; Received: Apr 23, 2014; Accepted: Apr 29, 2014; epub: May 10, 2014; ppub: May 2014

Keywords: Echocardiography; Atrial Fibrillation; Hypertension

Dear Editor,

Left atrial function is often under-evaluated in the standard echo examination, although this chamber plays a key role in heart function. Probably, mis or late diagnoses of atrial dysfunction are due to technical difficulties such as the thin wall thickness, the lack of robust parameters for functional assessment, and the number of factors potentially affecting or influencing the atrial activity. On the other hand, clinical studies have demonstrated that left atrial dysfunction heavily impacts on morbidity and mortality (1-3). Strain and strain rate imaging (S-SR) is a new echo technique able to study ventricular and atrial function. In particular, S-SR is capable of verifying the elasticity of the atrial wall, bearing in mind that increased atrial stiffness is linked to atrial fibrosis and (as a consequence) to higher arrhythmic risk. Many factors are involved in atrial stiffness such as age, diabetes, hypertension, valvulopathies, obesity, cigarette smoking, left ventricular diastolic function, left ventricular hypertrophy, myocardial infarction, arrhythmias, and dyslipidemia as well as its duration. In their study, Sahebjam et al. (4) found that hypertension was the only determinant of S-SR impairment, although in multivariate analysis, none of the parameters (including systolic and diastolic blood pressure) correlated with atrial S-SR. These data, as well as the differences with the studies cited in the article (5), are not surprising given the high prevalence of comorbidity after the fifth decade of life. In addition, disease duration, early diagnosis, therapy efficacy, class(es) of the drug used, and relative dose are all “confounding factors” and are as such hard to be controlled. For these reasons, very large cohorts are needed to give statistical power to such a complex multivariate analysis. The impact of a single factor on atrial S-SR could be studied in pediatric age (6), when comorbidities and drug use are less common. Unfortunately, in pediatric age, it is difficult to demonstrate the clinical relevance of the results obtained. On the other hand, large population studies on adults have shown that, independent of specific causes, impaired diastolic function is related to higher mortality and morbidity(7).

The results obtained by Sahebjam et al. demonstrate that, despite normal left atrial volumes, S-SR is lower in patients with one or more cardiovascular risk factors, increasing the evidence of high sensibility of this technique for screening higher-risk patients in different morbid conditions (8). In this way, S-SR could be a precious parameter of a bad outcome: left atrial volume enlargement could be, in fact, late evidence of diastolic dysfunction, and, at that time, the fibrotic process may be (at least partially) irreversible.

Limitations to a routine use of S-SR are due to inter-operator and inter-software variability (between speckle tracking and tissue Doppler or between two different software packages), poor familiarity of peripheral cardiologists with the technique, costs of special echo machines and software, time needed for post-processing, and lack of age-related normal values. However, S-SR imagingremains an essential method for a better understanding of the mechanic of the heart, an excellent research tool, and reliable software to settle tricky differential diagnoses. If, at the moment, its use is relegated to third-level cardiology centers, software improvements (in terms of reproducibility and automation) could open the way toward a routine use in the future.

Was this true glory? The high doom must be pronounced by times to come. Alessandro Manzoni, 5th May


Authors, Contribution: Both authors worked equally in writing the manuscript.
Financial Disclosure: There is no conflict of interest.


  • 1. Moller JE, Hillis GS, Oh JK, Seward JB, Reeder GS, Wright RS, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation. 2003;107(17):2207-12. [DOI] [PubMed]
  • 2. Welles CC, Ku IA, Kwan DM, Whooley MA, Schiller NB, Turakhia MP. Left atrial function predicts heart failure hospitalization in subjects with preserved ejection fraction and coronary heart disease: longitudinal data from the Heart and Soul Study. J Am Coll Cardiol. 2012;59(7):673-80. [DOI] [PubMed]
  • 3. Gupta S, Matulevicius SA, Ayers CR, Berry JD, Patel PC, Markham DW, et al. Left atrial structure and function and clinical outcomes in the general population. Eur Heart J. 2013;34(4):278-85. [DOI] [PubMed]
  • 4. Sahebjam M, Mazareei A, Lotfi-Tokaldany M, Ghaffari N, Zoroufian A, Sheikhfatollahi M. Comparison of Left Atrial Function between Hypertensive Patients with Normal Atrial Size and Normotensive Subjects Using Strain Rate Imaging Technique. Arch Cardiovasc Imaging. 2014;2(1):e16081 [DOI]
  • 5. Kokubu N, Yuda S, Tsuchihashi K, Hashimoto A, Nakata T, Miura T, et al. Noninvasive assessment of left atrial function by strain rate imaging in patients with hypertension: a possible beneficial effect of renin-angiotensin system inhibition on left atrial function. Hypertens Res. 2007;30(1):13-21. [DOI] [PubMed]
  • 6. Di Salvo G, Pacileo G, Del Giudice EM, Natale F, Limongelli G, Verrengia M, et al. Atrial myocardial deformation properties in obese nonhypertensive children. J Am Soc Echocardiogr. 2008;21(2):151-6. [DOI] [PubMed]
  • 7. Mogelvang R, Sogaard P, Pedersen SA, Olsen NT, Marott JL, Schnohr P, et al. Cardiac dysfunction assessed by echocardiographic tissue Doppler imaging is an independent predictor of mortality in the general population. Circulation. 2009;119(20):2679-85. [DOI] [PubMed]
  • 8. Vieira MJ, Teixeira R, Goncalves L, Gersh BJ. Left Atrial Mechanics: Echocardiographic Assessment and Clinical Implications. J Am Soc Echocardiogr. 2014;27(5):463-78. [DOI] [PubMed]