A Dodge-Khatami

A Hoffmann

B. J. M. Mulder

E. E. van der Wall

ET Velde Van der

F Meijboom

HJ Willens

II Tulevski

J Zedde Van der

JGJ Neffke

LF Tops

MG Duffels

MGJ Duffels

P Engelfriet

P Moons

PM Engelfriet

RL Loon Van

T Oosterhof

WP Abhayaratna

English

PubMed

Springer - Publisher Connector

EDITORIAL COMMENT
Size and function of the atria
B. J. M. Mulder Æ E. E. van der Wall
Received: 19 May 2008 / Accepted: 19 May 2008 / Published online: 4 June 2008
 The Author(s) 2008
Assessment of atrial size, anatomy and function is
important in various clinical settings and can be
performed with different imaging techniques. Assess-
ment of atrial size provides important prognostic
information and is routinely performed with trans-
thoracic echocardiography. Information on regional
atrial function can also be provided by transthoracic
echocardiography and is important in the setting of
treatment of atrial fibrillation. Catheter ablation
procedures for atrial fibrillation require accurate
imaging of the left atrium and surrounding structures.
Intracardiac echocardiography, multislice computed
tomography (CT), and cardiovascular magnetic res-
onance imaging (CMR) may provide detailed
information on right and left atrium and pulmonary
vein anatomy [1].
The atria perform three different functions during
the various phases of the cardiac cycle, i.e. serving as
reservoir during systole, passive conduit during early
diastole, and booster function during late diastole. In
this issue of the journal, Willens et al. report a
descriptive study on the effects of age and pulmonary
arterial hypertension on all three phases of right atrial
function by measuring changes in right atrial volume
during the cardiac cycle using two-dimensional
transthoracic echocardiography [2]. In their study,
Willens et al demonstrated that passive right atrial
emptying was lower and booster function was greater
in older healthy subjects and in patients with
pulmonary arterial hypertension. Reservoir function
was higher in pulmonary hypertension. These
changes are analogous to the changes reported in
the left atrium in response to increased afterload and
impaired relaxation [3].
The active contractile component of the atria has
an important role in patients with ventricular dys-
function to augment ventricular volume. Augmented
atrial booster function is one of the mechanisms
compensating for decreased early filling in patients
with reduced ventricular compliance. Loss of atrial
contraction as a result of atrial fibrillation or ventric-
ular pacing reduces cardiac output by approximately
15–20%. The ability to optimally redistribute ven-
tricular filling among reservoir, conduit and booster
pump functions is a potentially important adaptation
that may occur in the atria in response to changing
dynamics.
In patients with congenital or valvular heart
disease, increased ventricular stiffness or decreased
ventricular compliance may cause an increased atrial
B. J. M. Mulder
Department of Cardiology, Academic Medical Centre,
Amsterdam, The Netherlands
B. J. M. Mulder
Department of Cardiology, University Medical Centre
Utrecht, Utrecht, The Netherlands
E. E. van der Wall (&)
Department of Cardiology, Leiden University Medical
Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
e-mail: E.E.van_der_Wall@lumc.nl
123
Int J Cardiovasc Imaging (2008) 24:713–716
DOI 10.1007/s10554-008-9323-3
pressure. The increased atrial wall tension leads to
stretch and dilation of the atrial myocardium. Thus,
atrial volume increases with severity of diastolic
dysfunction.
Atrial volume is a barometer of ventricular filling
pressure and reflects the burden of diastolic dysfunc-
tion in subjects without atrial fibrillation or
significant valve disease. Atrial enlargement carries
important clinical and prognostic implications [1, 3].
In large population- based studies it has been
demonstrated that left atrial size is an important
predictor of cardiovascular outcome. Elevation of
filling pressure is uniformly found in the presence of
symptomatic congestive heart failure. Evidence for a
prognostic role for left atrial volume to predict
incident congestive heart failure is emerging [3]. In
the general population left atrial size has been
determined to be a predictor of stroke and death.
The relationship between left atrial size and death has
been demonstrated in high-risk groups, such as
patients with dilated cardiomyopathy, left ventricular
dysfunction, atrial arrhythmias, acute myocardial
infarction, patients undergoing valve replacement
for aortic valve stenosis and mitral regurgitation [3].
Left atrial size is potentially modifiable with
medical therapy, but whether left atrial size reduction
translates to improved outcomes remains to be
established.
Atrial fibrillation is another important factor
associated with atrial dilatation. Atrial enlargement
may be the consequence of atrial fibrillation, but
atrial enlargement may also lead to atrial fibrillation
[1, 3]. To what extent the shifts among reservoir,
conduit and booster pump functions of the atria
contribute to the development of atrial arrhythmias
warrants further study.
The atria play an important role in adult congenital
heart disease [4]. Atrial function is often altered due
to longstanding pressure or volume overload. More-
over, many adult patients with a congenital heart
defect have had intracardiac surgery with the use of
cardiopulmonary bypass in the past. These patients
will all have a right atrial scar, the sequel of the
atriotomy necessary for the cannulation for the
cardiopulmonary bypass or necessary for visualisa-
tion of intracardiac structures. This scarring leads to
loss of atrial compliance and compromises atrial
reservoir function. Moreover, atrial function can be
substantially modified by some forms of surgical
correction or palliation, such as the Mustard or
Senning procedure in patients with transposition of
the great arteries or a Fontan operation in patients
with univentricular hearts [5–10]. Cardioplegic arrest
may also cause deterioration of right atrial function.
Altered caval vein flow patterns indicate abnormal
atrial filling and the reservoir function of the right
atrium is diminished postoperatively. Both the long-
standing atrial overload and the atrial scarring form
substrates for atrial arrhythmias. Loss of atrial
reservoir function (reduced compliance) and the loss
of booster function (atrial fibrillation) is poorly
tolerated in patients with a compromised ventricular
function.
In patients with right ventricular hypertrophy, such
as in pulmonary arterial hypertension or in corrected
tetralogy of Fallot, the forceful right ventricular
contraction leads to an increased downward displace-
ment of the tricuspid valve annulus, thereby
increasing atrial filling from the pulmonary veins
during systole. The antegrade pulmonary flow during
diastole is decreased due to a decreased compliance.
The higher filling pressures will cause a more forceful
atrial contraction. Right ventricular volume overload,
due to pulmonary regurgitation and/or tricuspid
regurgitation in Fallot patients will also elevate right
atrial pressure and volume. Either due to elevated
right ventricular pressure or as a result of increased
right ventricular volume, the right atrial wall is often
stretched in patients with corrected tetralogy of
Fallot. This will not only lead to an altered atrial
function, but also to a high prevalence of atrial
arrhythmias. In case of atrial fibrillation, the contri-
bution of the atrial booster will then disappear, which
may substantially worsen the hemodynamic status in
these patients [11–22].
The longterm prognosis of adult patients with
congenital heart disease is insufficiently known and
largely dependent on right-sided cardiac function
[23–26]. Noninvasive follow-up modalities are of
utmost importance for these patients, in order to
allow early detection of pressure or volume overload
of the right ventricle before the occurrence of failure
or irreversible myocardial damage. Early detection of
right ventricular dysfunction may allow timely med-
ical management and preventive surgery. CMR
provides the diagnostic imaging of choice for the
evaluation of right sided heart anatomy and function
in congenital heart disease by its potential to obtain
714 Int J Cardiovasc Imaging (2008) 24:713–716
123
both anatomic detail and flow quantification [27–29].
CMR is useful for detecting intra- and extra-cardiac
conduit obstruction following cardiac surgery in
complex congenital heart disease. Technical
advances of CMR are the excellent spatial resolution,
the characterisation of myocardial tissue, multiplane
versatility and the potential for three-dimensional
imaging. By means of dobutamine stress cardiac
reserve may be determined in various forms of
congenital heart disease. In addition, the use of
plasma neurohormones may play a role in early
detection of cardiac dysfunction in asymptomatic
patients with congenital heart defects [30–35].
The utility of atrial volume and function for
monitoring cardiovascular risk and for guiding ther-
apy becomes increasingly clear and may prove to
have an important impact in clinical decision making.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which
permits any noncommercial use, distribution, and reproduction
in any medium, provided the original author(s) and source are
credited.
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716 Int J Cardiovasc Imaging (2008) 24:713–716
123


Size and function of the atria

Crossref

Adherence to guidelines in the clinical care for adults with congenital heart disease. The Euro Heart Survey on adult congenital heart disease.

Cardiovascular magnetic resonance in a pregnant patient with absent pulmonary valve syndrome.

Combined utility of brain natriuretic peptide and cardiac troponine T may improve rapid triage and risk stratiﬁcation in normotensive patients with pulmonary embolism.

Comparable systemic ventricular function in healthy adults and patients with unoperated congenitally corrected transposition using MRI dobutamine stress testing. Ann Thorac Surg 73:1759–1764

CONCOR, an initiative towards a national registry and DNA-bank of patients with congenital heart disease in the Netherlands: rationale, design, and ﬁrst results.

De Roos A

Delivery of care for adult patients with congenital heart disease in Europe: results from the Euro Heart Survey.

Dobutamineinduced increase of right ventricular contractility without increased stroke volume in adolescent patients with transposition of the great arteries: evaluation with magnetic resonance imaging.

Dodge-Khatami A et al (2002) Quantitative assessment of the pressure and volume overloaded right ventricular function: imaging is a real challenge.

Dodge-Khatami A et al (2003) Effect of pulmonary valve regurgitation on right ventricular function in patients with chronic right ventricular pressure overload.

Dodge-Khatami A et al (2004) Regional and global right ventricular dysfunction in asymptomatic or minimally symptomatic patients with congenitally corrected transposition of the great arteries. Cardiol Young 14:168–173

Duffels MG et al (2007) Long-term effect of bosentan in adults versus children with pulmonary arterial hypertension associated with systemicto-pulmonary shunt: does the beneﬁcial effect persist?

ECG determinants in adult patients with chronic right ventricular pressure overload due to congenital heart disease: relation with plasma neurohormones and MRI parameters.

Effects of age and pulmonary arterial hypertension on the different phases of right atrial function.

Effects of volume and/or pressure overload secondary to congenital heart disease (tetralogy of Fallot or pulmonary stenosis) on right ventricular function using cardiovascular magnetic resonance and B-type natriuretic peptide levels.

Increased brain and atrial natriuretic peptides dysfunction in patients with chronic right ventricular pressure overload: correlation between plasma neurohormones and right ventricular dysfunction. Heart 86:27–30 716 Int J Cardiovasc Imaging

Left atruial size. Physiologic determinants and clinical applications.

Meijboom FJ et al (2007) Longterm effect of pulmonary valve replacement on QRS duration in patients with corrected tetralogy of Fallot.

Mo ¨ller T et al (2007) Pulmonary arterial hypertension in adults born with a heart septal defect: the Euro Heart Survey on adult congenital heart disease.

Multi-modality imaging to assess left atrial size, anatomy and function.

Oechslin E et al (2005) The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. The Euro Heart Survey on adult congenital heart disease.

Pulmonary arterial hypertension associated with a congenital heart defect: advanced medium-term treatment stabilizes clinical condition. Congenit Heart Dis 2:242–249

Pulmonary arterial hypertension in congenital heart disease: an epidemiologic perspective from a Dutch registry.

Radiation exposure during follow-up of adults with congenital heart disease.

Repaired and open atrial septal defects type II in Int J Cardiovasc Imaging

Right ventricular function in congenital cardiac disease: noninvasive quantitative parameters for clinical follow-up. Cardiol Young 13:397–403

Roest AAW et al (2005) Disparity between dobutamine stress and physical exercise magnetic resonance imaging in patients with an intra-atrial correction for transposition of the great arteries.

The role of the atria in congenital heart disease.

Tulevski II et al (2005) Comparison of segmental and global systemic ventricular function at rest and during dobutamine stress between patients with transposition and congenitally corrected transposition. Cardiol Young 15:148–153

Usefulness of MRI dobutamine stress in asymptomatic and minimally symptomatic patients with decreased cardiac reserve from congenital heart disease.

Utility of a B-Natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism.

Vliegen HW et al (2006) Longterm follow up of homograft function after pulmonary valve replacement in patients with tetralogy of Fallot.

Vliegen HW et al (2007) Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance.

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Size and function of the atria

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