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Left atrial enlargement

Dr Rohit Sharma and A.Prof Frank Gaillard ◉ ◈ et al.

Left atrial enlargement may result from many conditions, either congenital or acquired. It has some
characteristic findings on a frontal chest radiograph. CT or MRI may also be used for diagnosis.

On this page:
Article:

Clinical presentation
Pathology
Radiographic features
Practical points
Video tutorial
Related articles
References

Images:

Cases and figures

Clinical presentation

An enlarged left atrium can have many clinical implications, such as:

Ortner syndrome: left recurrent laryngeal nerve palsy secondary to compression from enlarged left atrium
dysphagia megalatriensis: compression of oesophagus between the enlarged left atrium and vertebral
bodies
atrial fibrillation: via a multiple wavelet mechanism
thromboembolic events (e.g. ischaemic stroke): due to stasis of blood in the enlarged left atrium
(especially the left atrial appendage) and/or atrial fibrillation

Pathology

Broadly speaking, the causes of left atrial enlargement can be divided into congenital and acquired causes:

acquired
mitral stenosis
mitral regurgitation
left ventricular failure
left atrial myxoma
atrial fibrillation
it is uncertain if this a cause or only a consequence 10
congenital
ventricular septal defect (VSD)
patent ductus arteriosus (PDA)
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The common mechanism is increased atrial wall tension due to increased filling pressures, which eventually
leads to atrial enlargement.

There are associations between left atrial enlargement and atrial fibrillation, stroke, and mortality after
myocardial infarction. With a reduced incidence of mitral valve disease from rheumatic fever, the incidence of
left atrial enlargement has also decreased.

Radiographic features

Cardiac chamber enlargement is best assessed volumetrically with echocardiography and more recently (but less
widespread) with CT and MRI. Chest x-rays, however, are so frequently obtained, and formed the mainstay of
chest imaging for decades, that a great deal has been written about the various appearances of chamber
enlargement. It is, therefore, essential to be familiar with normal cardiomediastinal outlines.

Plain radiograph

As the left atrium enlarges, it may become directly visible, or displace adjacent structures.

Direct visualisation of the enlarged atrium includes:

double density sign

when the right side of the left atrium pushes into the adjacent lung, and becomes visible
superimposed or even beyond the normal right heart border (known as atrial escape)
a similar appearance can be caused by the right superior pulmonary vein in patients without atrial
enlargement 4
oblique measurement of greater than 7cm 5-6
measured from midpoint of left main bronchus to the right border of the left atrium (this requires a
double density sign of course)
thought to be the most reliable sign on chest radiography
convex left atrial appendage (third mogul sign): normally the left heart border just below the pulmonary
outflow track should be flat or slightly concave

Indirect signs include:

splaying of the carina, with the increase of the tracheal bifurcation angle to over 90 degrees
this refers to both the interbronchial angle (i.e., angle formed by the central axis of the left and right
main bronchi) and the subcarinal angle 1-3
both are inaccurate and dependent on radiographer technique, inspiration and body habitus 2
the mean and range of both measurements vary widely in normal individuals 2-3
interbronchial angle: normal mean 67-77° (with a range 34-109°)
subcarinal angle: normal mean 62-73° (range 34-90°)
posterior displacement of the left mainstem bronchus on the lateral radiograph
right and left bronchi, therefore, do not overlap, but rather form an upside down 'V', sometimes
referred to as the walking man sign 5
superior displacement of the left mainstem bronchus on frontal view
posterior displacement of a barium-filled oesophagus or nasogastric tube

CT and MRI

CT and MRI measurements of the left atrium rely on echocardiography data 7. Measurement is made at end
ventricular systole when the left atrium is the maximum size.

normal left atrial AP diameter

women: <4.0 cm
men: <4.1 cm

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An accurate AP measurement is made on the three-chamber view on a gated cardiac CT. The AP left atrial
diameter on a nongated contrast enhanced CT can only be an estimate since foreshortening of the chamber and
the cardiac cycle cannot be accounted for.

Atrial volume measurements are considered more accurate than either an AP measurements or area
measurements. The atrial volume can be calculated with: 8/3π[(area of the four chamber view)*(area of the two
chamber view)/(shortest inferior-superior length from the annular plane to the back wall of the atrium)]

normal atrial volume

women: <53 ml
men: <59 ml

One thing to remember is that echocardiography data for left atrial enlargement slightly underestimates the
volume of the left atrium made by CT, so one must be careful not to overcall mild left atrial enlargement on CT
8.

Practical points

left atrial enlargement is associated with thrombus formation (check the left atrial appendage)

Video tutorial

References
Related articles

Chest x-ray

chest x-ray
approach[+]
chest x-ray in the exam setting[+]
cardiomediastinal contour
cardiac silhouette
enlargement of the cardiac silhouette
right atrial enlargement
left atrial enlargement
right ventricular enlargement
left ventricular enlargement
cavo-atrial junction
aortic nipple
cardiothoracic ratio
vascular pedicle
moguls of the heart
chest radiograph zones[+]
fissures[+]
normal chest x-ray appearance of the diaphragm[+]
nipple shadow[+]
lines and stripes[+]
spaces[+]
signs[+]

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URL of Article https://radiopaedia.org/article

Article information
rID: 12944
Systems: Cardiac, Chest
Tags: chest x-ray, cxr, cardiac, cardiac ct
Synonyms or Alternate Spellings:

Enlargement of the left atrium

Left atrial dilatation
Enlargement of left atrium

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Cases and figures

Figure 1: normal PA cardiomediastinal outlinesFigure 1: normal PA cardiomediastinal outlines

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Case 1 Case 1
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Figure 2: normal lateral cardiomediastinal outlinesFigure 2: normal lateral cardiomediastinal outlines
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Case 1: double denistyCase 1: double denisty

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Figure 3: diagram (frontal)Figure 3: diagram (frontal)

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Case 1: atrial diameterCase 1: atrial diameter
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Figure 4: diagram (frontal) Figure 4: diagram (frontal)

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Case 1: subcarinal angleCase 1: subcarinal angle

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Figure 5: diagram (lateral)Figure 5: diagram (lateral)
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Case 2: with posterior oesophageal displacementCase 2: with posterior oesophageal displacement

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Figure 6: diagram (lateral with walking man sign)Figure 6: diagram (lateral with walking man sign)
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Case 3 Case 3
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Case 4Case 4
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Case 5Case 5
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Case 6Case 6
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Case 7Case 7
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Case 8: CTCase 8: CT
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Case 9Case 9
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Case 10: walking man signCase 10: walking man sign

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Case 11Case 11
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