How to Calculate Left Atrial Pressure (LAP) on ECHOCARDIOGRAPHY

 

Watch above example case and try to estimate LAP with the given information.

Left atrial pressure (LAP) is a crucial hemodynamic parameter that reflects the pressure within the left atrium. Echocardiography provides a non-invasive means to estimate LAP using various parameters.

To estimate LAP, several parameters are used, including mitral inflow pattern, tissue Doppler imaging (TDI) of the mitral annulus, pulmonary venous flow, and left atrial volume index (LAVI).

1. Mitral inflow pattern is assessed by measuring the peak velocity of the early diastolic filling (E wave) and late diastolic filling (A wave) using pulsed-wave Doppler. The E/A ratio can indicate diastolic function and LAP.

2. TDI of the mitral annulus measures the early diastolic velocity (E') of the mitral annulus. The E/E' ratio correlates well with LAP.

3. Pulmonary venous flow is assessed using pulsed-wave Doppler, measuring the systolic (S) and diastolic (D) flow velocities and calculating the S/D ratio.

4. LAVI is measured using the biplane method of disks (modified Simpson’s rule) and indexed to body surface area (BSA).

To calculate LAP, follow these steps:

1. Optimize image quality to ensure clear visualization of the mitral inflow, mitral annulus, and pulmonary veins.

2. Measure mitral inflow using pulsed-wave Doppler to obtain E and A wave velocities.

3. Measure mitral annular velocities using TDI to obtain E' at the septal and lateral mitral annulus.

4. Calculate the E/E' ratio by dividing the E wave velocity by the E' velocity (average of septal and lateral E' is often used).

5. Assess pulmonary venous flow by measuring S and D wave velocities in the pulmonary veins.

6. Calculate LAVI by measuring LA volume and indexing it to BSA.

Interpretation of these parameters can provide insights into LAP:

- E/E' ratio < 8 suggests normal LAP, while > 15 indicates elevated LAP. Ratios between 8 and 15 are less certain.

- LAVI > 34 mL/m² suggests chronic elevation of LAP.

- Decreased S/D ratio in pulmonary venous flow may indicate elevated LAP.

Echocardiographic estimation of LAP can be influenced by multiple factors, including operator skill, image quality, and patient-specific conditions. In some cases, invasive measurement via catheterization may be necessary for precise LAP determination. By combining these parameters and considering the clinical context, clinicians can estimate LAP and gain valuable insights into cardiac function and hemodynamics.