BACKGROUND: Left atrial (LA) enlargement is a predictor of worse outcome after catheter ablation for atrial fibrillation (AF). Widely used two-dimensional (2D)-echocardiography is inaccurate and underestimates real LA volume (LAV). We hypothesized that baseline clinical characteristics of patients can be used to adjust 2D-ECHO indices of LAV in order to minimize this disagreement. METHODS: The study enrolled 535 patients (59 ± 9 years; 67% males; 43% paroxysmal AF) who underwent catheter ablation for AF in three specialized centers. We investigated multivariately the relationship between 2D-echocardiographic indices of LA size, specifically LA diameter in M-mode in the parasternal long-axis view (LAD), LAV assessed by the prolate-ellipsoid method (LAVEllipsoid), LAV by the planimetric method (LAVPlanimetry), and LAV derived from 3D-electroanatomic mapping (LAVCARTO). RESULTS: Cubed LAD of 106 ± 45 ml, LAVEllipsoid of 72 ± 24 ml and LAVPlanimetry of 88 ± 30 ml correlated only modestly (r = 0.60, 0.69, and 0.53, respectively) with LAVCARTO of 137 ± 46 ml, which was significantly underestimated with a bias (±1.96 standard deviation) of -31 (-111; +49) ml, -64 (-132; +2) ml, and -49 (-125; +27) ml, respectively; p < 0.0001 for their mutual difference. LA enlargement itself, age, gender, type of AF, and the presence of structural heart disease were independent confounders of measurement error of 2D-echocardiographic LAV. CONCLUSION: Accuracy and precision of all 2D-echocardiographic LAV indices are poor. Their agreement with true LAV can be significantly improved by multivariate adjustment to clinical characteristics of patients.

2nd Department of Medicine Department of Cardiovascular Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

Department of Cardiology and Angiology St Anne's University Hospital and International Clinical Research Center Brno Czech Republic

Department of Cardiology Heart Centre Hospital Podlesi Trinec Czech Republic

Department of Cardiology Hospital Ceske Budejovice and Faculty of Health and Social Studies University of South Bohemia Ceske Budejovice Czech Republic

Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Internal Medicine and Cardiology University Hospital Masaryk University Brno Czech Republic

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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012;14:528–606. 10.1093/europace/eus027 PubMed DOI

Berruezo A, Tamborero D, Mont L, Benito B, Tolosana JM, Sitges M, et al. Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation. Eur Heart J. 2007;28:836–41. PubMed

von Bary C, Dornia C, Eissnert C, Nedios S, Roser M, Hamer OW, et al. Predictive value of left atrial volume measured by non-invasive cardiac imaging in the treatment of paroxysmal atrial fibrillation. J Interv Card Electrophysiol. 2012;34:181–8. 10.1007/s10840-011-9641-6 PubMed DOI

Zhuang J, Wang Y, Tang K, Li X, Peng W, Liang C, et al. Association between left atrial size and atrial fibrillation recurrence after single circumferential pulmonary vein isolation: a systematic review and meta-analysis of observational studies. Europace. 2012;14:638–45. 10.1093/europace/eur364 PubMed DOI

Lester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical practice and in research studies to determine left atrial size. Am J Cardiol. 1999;84:829–32. PubMed

Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440–63. PubMed

Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39. 10.1016/j.echo.2014.10.003 PubMed DOI

Badano LP, Pezzutto N, Marinigh R, Cinello M, Nucifora G, Pavoni D, et al. How many patients would be misclassified using M-mode and two-dimensional estimates of left atrial size instead of left atrial volume? A three-dimensional echocardiographic study. J Cardiovasc Med. 2008;9:476–84. PubMed

Hof I, Arbab-Zadeh A, Scherr D, Chilukuri K, Dalal D, Abraham T, et al. Correlation of left atrial diameter by echocardiography and left atrial volume by computed tomography. J Cardiovasc Electrophysiol. 2009;20:159–63. 10.1111/j.1540-8167.2008.01310.x PubMed DOI

Vandenberg BF, Weiss RM, Kinzey J, Acker M, Stark CA, Stanford W, et al. Comparison of left atrial volume by two-dimensional echocardiography and cine-computed tomography. Am J Cardiol. 1995;75:754–7. PubMed

Rodevan O, Bjornerheim R, Ljosland M, Maehle J,Smith HJ,Ihlen H. Left atrial volumes assessed by three- and two-dimensional echocardiography compared to MRI estimates.1999;15:397–410. PubMed

Mor-Avi V, Yodwut C, Jenkins C, Kuhl H, Nesser HJ, Marwick TH, et al. Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with CMR. JACC Cardiovasc Imaging. 2012;5:769–77. 10.1016/j.jcmg.2012.05.011 PubMed DOI

Piorkowski C, Hindricks G, Schreiber D, Tanner H, Weise W, Koch A, et al. Electroanatomic reconstruction of the left atrium, pulmonary veins, and esophagus compared with the "true anatomy" on multislice computed tomography in patients undergoing catheter ablation of atrial fibrillation. Heart Rhythm. 2006;3:317–27. PubMed

Patel VV, Ren JF, Jeffery ME, Plappert TJ, John Sutton MG, Marchlinski FE. Comparison of left atrial volume assessed by magnetic endocardial catheter mapping versus transthoracic echocardiography. Am J Cardiol. 2003;91:351–4. PubMed

Müller H, Burri H, Gentil P, Lerch R, Shah D. Measurement of left atrial volume in patients undergoing ablation for atrial fibrillation: comparison of angiography and electro-anatomic (CARTO) mapping with real-time three-dimensional echocardiography. Europace. 2010;12:792–7. 10.1093/europace/euq031 PubMed DOI

Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. J Am Soc Echocardiogr. 2011;24:229–67. 10.1016/j.echo.2010.12.008 PubMed DOI

Cozma D, Popescu BA, Lighezan D, Lucian P, Mornos C, Ginghina C, et al. Left atrial remodeling: assessment of size and shape to detect vulnerability to atrial fibrillation. Pacing Clin Electrophysiol.2007;30:S147–50. PubMed

Tsao HM, Yu WC, Cheng HC, Wu MH, Tai CT, Lin WS, et al. Pulmonary veindilation in patients with atrial fibrillation: detection by magnetic resonance imaging. J Cardiovasc Electrophysiol. 2001;12:809–13. PubMed

Kurotobi T, Iwakura K, Inoue K, Kimura R, Toyoshima Y, Ito N, et al. The significance of the shape of the left atrial roof as a novel index for determining the electrophysiological and structural characteristics in patients with atrial fibrillation. Europace.2011;13:803–8. 10.1093/europace/eur039 PubMed DOI

Nedios S, Tang M, Roser M, Solowjowa N, Gerds-Li JH, Fleck E, et al. Characteristic changes of volume and three-dimensional structure of the left atrium in different forms of atrial fibrillation: predictive value after ablative treatment. J Interv Card Electrophysiol.2011;32:87–94. 10.1007/s10840-011-9591-z PubMed DOI

Bisbal F, Guiu E, Calvo N, Marin D, Berruezo A, Arbelo E, et al. Left atrial sphericity: a new method to assess atrial remodeling. Impact on the outcome of atrial fibrillation ablation. J Cardiovasc Electrophysiol.2013;24:752–9. 10.1111/jce.12116 PubMed DOI

Nikitin NP, Witte KA, Thackray SDR, Goodge LJ, Clark AL, Cleland JGF. Effect of age and sex on left atrial morphology and function. Eur J Echocardiography. 2013;4:36–42. PubMed

Maceira AM, Cosín-Sales J, Roughton M, Prasad SK, Pennell DJ. Reference left atrial dimensions and volumes by steady state free precession cardiovascular magnetic resonance. Journal of Cardiovascular Magnetic Resonance. 2010;12:65 10.1186/1532-429X-12-65 PubMed DOI PMC

Ujino K, Barnes ME, Cha SS, Langins AP, Bailey KR, Seward JB, et al. Two-dimensional echocardiographic methods for assessment of left atrial volume. Am J Cardiol. 2006;98:1185–8. PubMed

Ejima K, Shoda M, Yagishita D, Futagawa K, Yashiro B, Sato T, et al. Image integration of three-dimensional cone-beam computed tomography angiogram into electroanatomical mapping system to guide catheter ablation of atrial fibrillation. Europace.2010;12:45–51. 10.1093/europace/eup371 PubMed DOI

3D electroanatomical mapping is less sensitive to atrial remodeling in estimation of true left atrial volume than echocardiography