Left atrial size in childhood

J. ELECTROCARDIOLOGY 13 (1), 1980, 11-16

Left Atrial Size in Childhood BY THOMAS M. BIANCANIELLO, M.D., GEORGE S. BISSET III, M.D., WINSTON E. GAUM, M.D., RICHARD A. MEYER, M.D. AND SAMUEL KAPLAN, M.D.

SUMMARY To d e t e r m i n e t h e a c c u r a c y o f t h e d i a g n o s i s o f left a t r i a l e n l a r g e m e n t ( L A E ) by v e c t o r c a r d i o g r a m ( V C G ) a n d e l e c t r o c a r d i o g r a m ( E C G ) , we a n a l y z e d t h e m a g nitude of the P loop on VCG and the P wave duration, amplitude, and deflection on the ECG and compared them with echographic and angiographic data. T w e n t y - e i g h t c h i l d r e n w i t h L A E w e r e selected w h o h a d c o n g e n i t a l or a c q u i r e d h e a r t disease. T h e c o n t r o l p o p u l a t i o n c o n s i s t e d o f 24 c h i l d r e n w i t h n o r m a l left a t r i a l (LA) d i m e n s i o n s . No s i g n i f i c a n t d i f f e r e n c e in P w a v e a m p l i t u d e o r d u r a t i o n w a s f o u n d in t h e t w o g r o u p s o n E C G . N e g a t i v e t e r m i n a l d e f l e c t i o n 1> - 1 m m in V l p r e d i c t e d L A E in o n l y 25% o f t h e p a t i e n t s w i t h L A E . P l o o p m a g n i t u d e s in all v e c t o r p l a n e s s h o w e d c o n s i d e r a b l e o v e r l a p in b o t h g r o u p s . W h e n m a g n i t u d e a n d d i r e c t i o n w e r e c o n s i d e r e d o n V C G , o n l y 29% o f t h e pat i e n t s w i t h L A E w o u l d h a v e b e e n d i a g n o s e d as L A E by V C G c r i t e r i a . P a t i e n t s with large LA volumes, determined from biplane angiography, were compared w i t h e c h o c a r d i o g r a p h y , V C G a n d E C G . All h a d e c h o c a r d i o g r a p h i c L A E , 50% h a d L A E by E C G c r i t e r i a a n d o n l y 33% by V C G c r i t e r i a . I t is c o n c l u d e d t h a t m o r e sensitive E C G a n d V C G c r i t e r i a f o r d i a g n o s i n g L A E b y E C G a n d V C G n e e d to be d e v e l o p e d . I t m u s t a l s o be d e t e r m i n e d w h i c h o f t h e s e c h a n g e s c o r r e l a t e w i t h c o n d u c t i o n delay, a t r i a l h y p e r t r o p h y a n d / o r e n l a r g e m e n t .

divided into three groups: 0-2 years: seven patients; 2-10 years: ten patients; and 10-20 years: seven patients. These patients either did not have heart disease or had heart disease unassociated with LAE (one with a history of remote paroxysmal atrial tachycardia with a normal heart, three patients with pulmonic stenosis, two with small pericardial effusions, and two with mitral valve prolapse and trivial mitral incompetence). A normal left atrial dimension (LAD) was measured on echocardiogram in all p a t i e n t s in the control group. Twenty-eight children (13 males and 15 females) with LAE were selected who had congenital or acquired heart disease. We subdivided these into similar age groups: 0-2 years: seven patients; 2-10 years: 12 patients; and 10-20 years: nine patients. All these children had LAE measured by echocardiogram which was confirmed by angiography in 12 patients. Echocardiographic dimensions were recorded by M-mode and were measured from the posterior margin of the aorta (atrial side) to the LA wall during ventricular end systole at the level of the aortic root. These were measured after the scan from the mitral valve to aorta. The normal values for LAD have been established according to patient size in our laboratory. 4 LAE was defined as those values which exceeded the normals for size of patient by two standard deviations. VCGs were performed using the Frank lead system. The amplitude and direction of the P loop vectors were compared in both groups of patients. LAE is defined by VCG criteria as a posteriorly oriented P loop of greater magnitude than expected for age. 3

To d e t e r m i n e t h e a c c u r a c y of t h e d i a g n o s i s of left a t r i a l e n l a r g e m e n t (LAE) b y v e c t o r c a r d i o g r a m (VCG) a n d e l e c t r o c a r d i o g r a m (ECG), we a n a l y z e d t h e m a g n i t u d e of t h e P loop on VCG and the P wave duration, amplitude and deflection on t h e E C G , a n d c o m p a r e d t h e m to e c h o c a r d i o g r a p h i c a n d a n g i o g r a p h i c d a t a . We s t u d i e d t w o g r o u p s of c h i l d r e n . O n e g r o u p consisted of c h i l d r e n w i t h k n o w n L A E a n d t h e o t h e r w i t h n o r m a l left a t r i a (LA) size. S e v e r a l a u t h o r s h a v e s u g g e s t e d c r i t e r i a for L A E in children, 1'2'3 b u t c o r r e l a t i o n w i t h left a t r i a l d i m e n s i o n in c h i l d r e n b y e c h o c a r d i o g r a p h y a n d a n g i o g r a p h y h a s not b e e n e s t a b l i s h e d .

MATERIALS AND METHODS The control population of children consisted of 24 children (13 males and 11 females), whom we subFrom the Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine. Supported in part by U.S.P.H.S. Grant No. 5T332HL07417 and the American Heart Association, Southwestern Ohio Chapter. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked ' ~ a d v e r t i s e m e n t ~' in accordance with 18 U.S.C. w 1734 solely to indicate this fact. Reprint requests to: Children's Hospital Medical Center, Division of Cardiology, Elland & Bethesda Avenues, Cincinnati, Ohio 45229. 11

12

BIANCANIELLO

The maximum amplitude and duration of the P wave on ECG was measured and compared in both groups. Electrocardiographic criteria for LAE were: (1) P wave amplitude ~>2.5 mm; (2) P wave duration > .08 seconds; or (3) negative terminal deflection in V1/> - 1 mm. 5'~ Biplane angiographic LAD's were measured by planimetry, as described by Graham, et al., 7 and the volumes were calculated. The normal values were obtained from their regression equations, and the maximum LA size for each patient was determined by the formulas: LA max (CM a) = .6 (wt in kg.) + .49 (ht in cm) - .71 (age in years) - 34.8 for patients older than two years of age; and LA max (CM a) = 1.23 (wt in kg) - 0.07 (ht in cm) + 2.22 (age in years) + 4.1 for patients younger than two years of age. We have validated these equations in our laboratory. The statistical significance in the differences between means in this study were calculated using the Student's t test. All studies were performed w i t h i n 72 hours of each other. All d a t a was evaluated independently by each of the authors.

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RESULTS Fig. 1 c o m p a r e s the P w a v e a m p l i t u d e s bet w e e n t h e g r o u p w i t h n o r m a l L A size (on t h e left for e a c h age group), w i t h the a m p l i t u d e s of the g r o u p w i t h k n o w n L A E (on t h e r i g h t for e a c h age group). T h e r e is no s i g n i f i c a n t dif4.0 r-

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Fig. 2:. Comparison of P wave duration on ECG in patients with LAE and in normals. The short horizontal line represents the mean, the long horizontal lines represent 1 standard deviation.

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to r e p r e s e n t LAE, only seven of t h e 28 pat i e n t s (25%) w i t h k n o w n L A E could h a v e been c o n s i d e r e d to h a v e L A E by t h i s E C G criterion. F a l s e p o s i t i v e s are less c o m m o n in t h a t only two of t h e 24 p a t i e n t s (8%), of the

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Fig. 1: Comparison of P wave ampliture on ECG in patients with LAE and in normals. The short horizontal line represents the mean, the long horizontal lines represent 1 standard deviation. ference in P w a v e a m p l i t u d e b e t w e e n g r o u p s in a n y age category. T h e r e is c o n s i d e r a b l e overlap of a m p l i t u d e s b e t w e e n the n o r m a l s a n d L A E g r o u p s for e a c h age. R e l a t i v e l y few a m p l i t u d e s > 2.5 m V were o b t a i n e d in a n y age group. Fig. 2 c o m p a r e s t h e P w a v e d u r a tion for b o t h groups. T h e r e is c o n s i d e r a b l e overlap in v a l u e s b e t w e e n b o t h groups. T h e r e is no s i g n i f i c a n t difference in P wave d u r a t i o n b e t w e e n g r o u p s in a n y age category. W h e n isolated n e g a t i v e t e r m i n a l P w a v e deflection of ~> - 1 m m in V1 w a s considered

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Fig. 3: Comparison of P loop magnitude in horizontal on VCG in patients with LAE and in normals. The short horizontal line represents the mean, the long horizontal lines represent 1 standard deviation. J. E L E C T R O C A R D I O L O G Y , VOL. 13, NO. 1, 1980

LA SIZE IN CHILDHOOD

normal group, would have been considered to have LAE by ECG. Fig. 3 shows a comparison of the P loop vectors in the horizontal plane. The mean P loop magnitude in this plane correlated well with LAE in the 0-2 year and the 2-10 year age groups, with the difference in the 10-20 year age group mean being statistically insignificant between the two groups. However, there was an overlap of values in all groups. Fig. 4 represents the comparison of mean P loop magnitudes and values in the sagitta] plane for both groups. The difference between the o

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giography and echocardiography. Only 50% of these patients had LAE by ECG criteria and only 33% had LAE by VCG criteria. Fig. 6 illustrates the insensitivity of ECG and VCG for diagnosing LAE. This patient is a 131/2 year old male who has mild rheumatic mitral stenosis and aortic insufficiency. His LA dimension by M mode echocardiography was 3.0 cm. (normal for his size is 2.38 _+ 0.44 cm.). His ECG and VCG do not meet the criteria for LAE.

DISCUSSION It is unclear whether P wave changes are related to LA size, LA hypertrophy, atrial c o n d u c t i o n d e f e c t s or o t h e r p h e n o m e n a . Josephson, et al. s studied P wave changes in LAE in adults and compared them with those obtained by echocardiogram, atrial mapping during cardiac catheterization, LA pressures and LA volumes. They concluded that the classic broad notched P wave and negative terminal deflection of the P wave represented interatrial conduction delay, which they believed could be produced by a v a r i e t y of factors. Ikram, et al2 compared electrocardiography and echocardiography in adults to

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~0.18means in the sagittal P loop was statistically significant in only the 2-10 year age category. Again, there was considerable overlap of values with this group. Fig. 5 represents the mean P loop magnitudes and values in the frontal plane showing no significant differences between the normal and LAE groups. When both magnitude and orientation of the P loop were considered, only eight of the 28 p a t i e n t s (29%) with k n o w n LAE could have been predicted by VCG to have LAE. Table I compares the projected normal LA volumes with the measured LA volumes obtained by p l a n i m e t r y from biplane angiograms. These 12 patients were unselected and were the only ones in whom angiograms were obtained at the time the other studies were performed. All 12 patients had LAE by anJ. ELECTROCARDIOLOGY, VOL 13, NO. 1, 1980

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14

BIANCANIELLO

ET A L

TABLE 1. Angiographic, echographic, ECG and VCG data on patients with left atrial enlargement Angiography Normal Measured LA Volume TM LA Volume

Echo LAD/Normal

ECG Criteria For LAE

VCG Criteria For LAE

10.8

49.3

2.5/1.59(-+ .33)

yes

yes

29.1

78.0

2.8/1.72(+ .38)

no

yes

34.2

125.5

3.0/2.06(-+ .28)

no

no

21.4

168.8

4.0/1.72(_+ .38)

no

no

11.5

88.0

2.1/1.59(_+ .33)

yes

yes

30.4

151.0

4.0/2.06(_+ .28)

no

no

52.4

100.8

3.0/2.38(_+ .44}

no

no

62.8

136.3

3.0/2.38( _+ .44)

yes

no

20.8

96.6

2.8/1.72(_+ .38)

no

no

22.0

139.0

3.5/1.72(_+ .38)

yes

yes

34.1

356.0

2.3/2.06(_+ .28)

yes

no

61.2

182.0

3.9/2.78(-+ .53)

yes

no

*Normal for age, height and weight as determined by regression formula (see text). TABLE 1. A comparison of LA size by angiography, echocardiogram, ECG and VCG.

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Fig. 6: Echocardiogram, ECG, and VCG from a patient with LAE and normal P wave and loop. J. ELECTROCARDIOLOGY, VOL. 13, NO. 1, 1980

LA SIZE IN CHILDHOOD

d e t e r m i n e w h i c h was more sensitive in predicting LAE. T h e y concluded t h a t echocard i o g r a p h y was m o r e s e n s i t i v e in d e t e c t i n g m i l d e r d e g r e e s of LAE. Waggoner, et al. 1~ c o m p a r e d e c h o c a r d i o g r a m s a n d E C G in 207 p a t i e n t s ages 10-87, a n d concluded E C G was r e a s o n a b l y specific b u t less sensitive t h a n the e c h o c a r d i o g r a m as a n indicator of LAE. S e v e r a l r e p o r t s from d a t a in children!l,~2,1a indicate that echocardiographic measurem e n t s c o r r e l a t e w i t h L A d i m e n s i o n a n d volu m e as d e t e r m i n e d by a n g i o g r a p h i c studies. O u r p a t i e n t s w i t h LAE, whose L A d i m e n s i o n s w e r e m e a s u r e d at cardiac c a t h e t e r i z a t i o n b y a n g i o g r a p h y , s u p p o r t e d these observations. O u r s t u d y suggests t h a t c u r r e n t electrocardiographic and v e c t o r c a r d i o g r a p h i c m e t h o d s a r e not s e n s i t i v e in e v a l u a t i n g L A size in c h i l d r e n . We c o n c l u d e t h a t m o r e s e n s i t i v e E C G and VCG c r i t e r i a for L A E in children n e e d to be developed. It m u s t also be determ i n e d w h i c h c h a n g e s c o r r e l a t e w i t h conduction delay, atrial hypertrophy and/or enlargement.

5.

6. 7.

8. 9.

10.

11. REFERENCES 1. ZIEGLER,R F: Electrocardiographic studies in n o r m a l i n f a n t s and children. Charles C. Thomas, Springfield, 1951 2. NADAS,A S AND FYLER,D C: Pediatric cardiology, 3rd Edition. W. B. Saunders Co., Philadelphia, 1972, p 45 3. MOSS, A J, ADAMS, F H AND EMMANOUILIDES, G C: Heart disease in infants, children and adolescents, 2nd Edition. The Williams and Wilkins Co., Baltimore, 1977, Chapters 3 and 4 4. MEYER,R A: Pediatric echocardiography. Lea

J. ELECTROCARDIOLOGY, VOL. 13, NO. 1, 1980

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13.

15

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