Vol 25, No 1 (2018)
Original articles — Clinical cardiology
Published online: 2017-06-12

open access

Page views 2201
Article views/downloads 2232
Get Citation

Connect on Social Media

Connect on Social Media

The value of left atrial strain and strain rate in predicting left atrial appendage stasis in patients with nonvalvular atrial fibrillation

Meng-Ruo Zhu, Man Wang, Xin-Xin Ma, Dong-Yan Zheng, Yue-Li Zhang
Pubmed: 28612903
Cardiol J 2018;25(1):87-96.


Background: This study aimed to investigate the value of left atrial (LA) strain and strain rate (S/SR) by transthoracic echocardiography (TTE) in predicting left atrial appendage (LAA) stasis, in order to find a way for LAA stasis screening which is easily performed in patients with nonvalvular atrial fibrillation (NVAF).

Methods: One hundred and thirty NVAF patients prepared for AF ablation were enrolled. TTE and transesophageal echocardiography (TEE) were performed in all patients. LA S/SR in each phase was analyzed off-line. LAA blood flow state and LAA function were assessed by using TEE.

Results: LA S/SRs during atrial reservoir phase (LA Sres/SRres) were significantly negatively cor­related with LAA spontaneous echo contrast (SEC) grade (r = −0.567 and −0.520, respectively; all p < 0.01), and positively correlated with LAA emptying fraction (r = 0.602 and 0.619, respectively; all p < 0.01) and with LAA peak emptying flow velocity (r = 0.623 and 0.642, respectively; all p < 0.01). The multivariate logistic regression analysis showed LA Sres to be the strongest independent predictor of LAA stasis, followed by LA volume index. LA Sres < 13% was recommended to predict LAA stasis with sensitivity of 90% and specificity of 74%.

Conclusions: LA Sres by TTE can noninvasively predict LAA stasis and may be used as a screening tool to assist in the detection of LAA stasis in patients with NVAF. (Cardiol J 2018; 25, 1: 87–96)

Article available in PDF format

View PDF Download PDF file


  1. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996; 61(2): 755–759.
  2. Providência R, Trigo J, Paiva L, et al. The role of echocardiography in thromboembolic risk assessment of patients with nonvalvular atrial fibrillation. J Am Soc Echocardiogr. 2013; 26(8): 801–812.
  3. Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus. Circulation. 1991; 84(1): 223–231.
  4. Vianna-Pinton R, Moreno CA, Baxter CM, et al. Two-dimensional speckle-tracking echocardiography of the left atrium: feasibility and regional contraction and relaxation differences in normal subjects. J Am Soc Echocardiogr. 2009; 22(3): 299–305.
  5. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64: e1–76.
  6. Lang RM, Badano LP, Mor-Avi V, 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): 1–39.e14.
  7. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994; 23(4): 961–969.
  8. Troughton RW, Asher CR, Klein AL. The role of echocardiography in atrial fibrillation and cardioversion. Heart. 2003; 89(12): 1447–1454.
  9. Lowe B, Kusunose K, Motoki H, et al. Prognostic Significance of Left Atrial Appendage “Sludge” in Patients with Atrial Fibrillation: A New Transesophageal Echocardiographic Thromboembolic Risk Factor. J Am Soc Echocardiogr. 2014; 27(11): 1176–1183.
  10. Omran H, Jung W, Rabahieh R, et al. Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography. Heart. 1999; 81(2): 192–198.
  11. Bernhardt P, Schmidt H, Hammerstingl C, et al. Patients at high risk with atrial fibrillation: a prospective and serial follow-up during 12 months with transesophageal echocardiography and cerebral magnetic resonance imaging. J Am Soc Echocardiogr. 2005; 18(9): 919–924.
  12. Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol. 2001; 37(3): 691–704.
  13. Tamura H, Watanabe T, Hirono O, et al. Low wall velocity of left atrial appendage measured by trans-thoracic echocardiography predicts thrombus formation caused by atrial appendage dysfunction. J Am Soc Echocardiogr. 2010; 23(5): 545–552.e1.
  14. Uretsky S, Shah A, Bangalore S, et al. Assessment of left atrial appendage function with transthoracic tissue Doppler echocardiography. Eur J Echocardiogr. 2009; 10(3): 363–371.
  15. Motoki H, Dahiya A, Bhargava M, et al. Assessment of left atrial mechanics in patients with atrial fibrillation: comparison between two-dimensional speckle-based strain and velocity vector imaging. J Am Soc Echocardiogr. 2012; 25(4): 428–435.
  16. Shimizu T, Takada T, Shimode A, et al. Association between paroxysmal atrial fibrillation and the left atrial appendage ejection fraction during sinus rhythm in the acute stage of stroke: a transesophageal echocardiographic study. J Stroke Cerebrovasc Dis. 2013; 22(8): 1370–1376.
  17. Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med. 1998; 128(8): 639–647.
  18. Kuppahally SS, Akoum N, Burgon NS, et al. Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation: relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ Cardiovasc Imaging. 2010; 3(3): 231–239.
  19. Steinberg BA, Hellkamp AS, Lokhnygina Y, et al. ROCKET-AF Steering Committee and Investigators. Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial. Eur Heart J. 2015; 36(5): 288–296.
  20. Providência R, Botelho A, Trigo J, et al. Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters. Europace. 2012; 14(1): 36–45.
  21. Saraiva RM, Demirkol S, Buakhamsri A, et al. Left atrial strain measured by two-dimensional speckle tracking represents a new tool to evaluate left atrial function. J Am Soc Echocardiogr. 2010; 23(2): 172–180.
  22. Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. Heart. 1999; 82(5): 547–554.
  23. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991; 22(8): 983–988.
  24. Kaya EB, Tokgözoglu L, Aytemir K, et al. Atrial myocardial deformation properties are temporarily reduced after cardioversion for atrial fibrillation and correlate well with left atrial appendage function. Eur J Echocardiogr. 2008; 9(4): 472–477.
  25. Tsai LM, Chen JH, Lin LJ, et al. Natural history of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation. Am J Cardiol. 1997; 80(7): 897–900.