What is the diagnosis for a patient with left atrial enlargement, normal left ventricle (LV) size, left ventricular ejection fraction (LVEF) of 55-60%, mild asymmetric septal hypertrophy, trace mitral regurgitation (MR) and tricuspid regurgitation (TR), and a moderately dilated aortic root?

From the Guidelines

The patient's echocardiogram findings indicate a need for regular monitoring, particularly for the moderately dilated aortic root/ascending aorta, and management of potential risk factors such as hypertension to prevent further dilation. The left atrium is mildly enlarged, which can be associated with conditions like hypertension or diastolic dysfunction, as noted in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1. The left ventricle has normal size and function with an ejection fraction of 55-60%, though there is mild asymmetric septal hypertrophy present. Diastolic function appears normal.

The trace regurgitation of both the mitral and tricuspid valves is generally considered physiologic and not clinically significant, according to the guidelines for valvular heart disease 1. The right-sided heart chambers are normal in size, and the pulmonary artery pressure is normal with RVSP <35mmHg. The pericardium is normal with no evidence of effusion.

Key points to consider in management include:

• Regular follow-up echocardiograms every 6-12 months to monitor the aortic dilation, as progressive enlargement beyond 50mm may warrant consideration of surgical intervention.
• Blood pressure control is essential to prevent further aortic dilation.
• The patient should be advised to avoid strenuous isometric exercises that can increase aortic wall stress.
• Monitoring for signs of mitral regurgitation (MR) severity, as outlined in the 2014 AHA/ACC guideline 1, is necessary, although the current trace regurgitation is not indicative of severe MR.
• Consideration of the patient's overall clinical presentation and integration of echocardiogram findings with other clinical evidence is crucial for appropriate management, as emphasized in the guideline 1.

From the Research

Left Atrium Enlargement

• The patient's echocardiography results show enlargement of the left atrium, which can be an indicator of advanced disease, as seen in a study on asymptomatic aortic stenosis 2.
• However, the study also notes that left atrial dilation may be associated with left ventricular remodeling and provides prognostic information in severe asymptomatic aortic stenosis 2.
• Another study suggests that left atrial size ought to be calculated from the apical two and four chambers view parameters, especially in patients with aortic root dilatation, as increases in aortic root impact on the linear measurement of left atrium, resulting in an underestimated left atrial diameter 3.

Aortic Root Dilatation

• The patient's echocardiography results show a moderately dilated aortic root, which can impact the assessment of left atrial size, as seen in a study on the distorted assessment of left atrial size by echocardiography in patients with increased aortic root diameter 3.
• The study found that the increase in left atrial size assessed in parasternal long axis did not correlate with the increase of left atrial volume, and that left atrial volume increase correlated with left atrial diameters assessed in the apical two and four chamber view regardless of aortic root size 3.

Prognostic Implications

• Left atrial dilation has been associated with reduced event-free survival in patients with bicuspid aortic valve and moderate to severe aortic regurgitation, as seen in a study on the prognostic implications of left atrial dilation in aortic regurgitation due to bicuspid aortic valve 4.
• The study found that dilated left atrial volume index was independently associated with reduced event-free survival after adjustment for left ventricular ejection fraction, aortic root diameter, left ventricular end-diastolic diameter, and left ventricular end-systolic diameter 4.

Clinical Evaluation

• Echocardiography is a key diagnostic modality for evaluation, diagnosis, and management of cardiac sources of embolism, including left atrial appendage thrombi, as seen in guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism 5.
• The guidelines provide comprehensive recommendations on the use of echocardiography for evaluation of cardiac sources of embolism, including the incremental value of contrast and 3D echocardiography, and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli 5.