How should I interpret an echocardiogram that shows a normal-sized left ventricle with normal wall thickness, preserved systolic function (ejection fraction 55‑60 %), normal diastolic parameters, an enlarged left atrium, trivial mitral regurgitation, and mild tricuspid regurgitation, and what management is recommended?

Echocardiogram Interpretation: Enlarged Left Atrium with Preserved Systolic Function

Your echocardiogram reveals severe left atrial enlargement that demands immediate investigation and aggressive management, even though your left ventricular systolic function is preserved. The enlarged left atrium is not a benign finding—it reflects chronic elevated left ventricular filling pressures and significantly increases your risk of atrial fibrillation, stroke, heart failure hospitalization, and mortality 1.

Understanding Your Results

Left Ventricular Function

• Your ejection fraction of 55-60% is normal (≥50-53% meets criteria) 1
• Normal left ventricular size, wall thickness, and systolic function are reassuring findings 1
• However, do not be falsely reassured by the "normal diastolic function" label when severe left atrial enlargement is present 1

The Critical Finding: Enlarged Left Atrium

• Severe left atrial enlargement (defined as volume index >48 mL/m²) provides independent prognostic information regardless of your normal ejection fraction 1
• The enlargement itself indicates chronic diastolic dysfunction independent of other diastolic parameters 1
• This finding signals a high likelihood of progression to heart failure with preserved ejection fraction (HFpEF) due to chronic diastolic dysfunction 1

Valve Findings

• Trivial mitral regurgitation is not hemodynamically significant and does not require specific intervention 2
• Mild tricuspid regurgitation is common and often asymptomatic 2
• However, functional tricuspid regurgitation can progress in the setting of left atrial enlargement and atrial fibrillation 3, 4

Immediate Diagnostic Workup Required

You must identify the underlying cause of your severe left atrial enlargement 1:

Primary Investigations

• Blood pressure assessment: Chronic hypertension is the most common driver of left atrial enlargement 1
• Rhythm monitoring: 24-hour Holter or extended monitoring to detect paroxysmal atrial fibrillation 1
• Pulmonary artery pressure measurement: Calculate from your tricuspid regurgitation jet velocity; if TR velocity >3 m/s (PASP >40 mmHg), this signals pulmonary hypertension requiring targeted therapy 1
• Comprehensive valve assessment: Ensure no missed mitral stenosis or more significant mitral regurgitation 1
• Consider infiltrative disorders: If no clear cause is found, evaluate for restrictive cardiomyopathy or infiltrative diseases 1

Additional Considerations

• Left ventricular hypertrophy is a known independent determinant of left atrial size, and abnormal LV geometry patterns (especially eccentric and concentric LVH) are independently associated with left atrial enlargement 5
• Both LV mass index and relative wall thickness are independent determinants of left atrial enlargement 5

Management Strategy

Blood Pressure Control

• Aggressive blood pressure control (<130/80 mmHg) is recommended when hypertension is present 1
• This is the single most important modifiable factor if hypertension is the underlying cause 1

Valve Disease Management

• Optimize treatment of any left-sided valvular disease, particularly mitral pathology, to mitigate further atrial remodeling 1
• Even though your mitral regurgitation is trivial now, monitor for progression 2

Monitoring and Follow-up

• Serial echocardiography every 6-12 months is advised given the severe atrial enlargement, or sooner if new symptoms develop 1
• Track the evolution of functional tricuspid regurgitation, right ventricular function, atrial size, and left ventricular systolic performance 1
• If dyspnea or reduced exercise tolerance emerges, cardiopulmonary exercise testing is recommended to evaluate functional capacity and hemodynamic response 1

Risk Stratification

• Be aware that the combination of significant functional mitral and tricuspid regurgitation, if it develops, predicts poor outcomes even with preserved ejection fraction 4
• Patients with longstanding atrial fibrillation and preserved LVEF who develop both significant MR and TR have an event-free rate of only 21% at 24 months 4

Critical Pitfalls to Avoid

• Do not dismiss severe left atrial enlargement solely because the ejection fraction is normal; it reflects significant chronic cardiac pathology that warrants investigation and management 1
• Do not rely on a "normal diastolic function" label when severe left atrial enlargement is present; the enlargement itself indicates chronic diastolic dysfunction 1
• Do not delay investigation of the underlying cause—this is not a "wait and see" situation 1
• Do not assume the trivial mitral and mild tricuspid regurgitation are inconsequential—monitor for progression, especially if atrial fibrillation develops 3, 4

Prognosis and Long-term Outlook

The presence of severe left atrial enlargement with preserved ejection fraction places you at significantly elevated risk for adverse cardiovascular outcomes 1. However, aggressive management of the underlying cause—particularly blood pressure control if hypertension is present—can prevent progression 1. The key is identifying and treating the root cause while maintaining close surveillance for complications such as atrial fibrillation, worsening valve regurgitation, or development of symptomatic heart failure 1.