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Cardiac imaging and non-invasive testing
Left atrial Frank–Starling law assessed by real-time, three-dimensional echocardiographic left atrial volume changes
  1. Ashraf M Anwar1,
  2. Marcel L Geleijnse2,
  3. Osama I I Soliman1,2,
  4. Attila Nemes2,
  5. Folkert J ten Cate2
  1. 1
    Cardiology Department, Al-Husein University Hospital, Al-Azhar University, Cairo, Egypt
  2. 2
    Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands
  1. Dr F J Ten Cate, Thoraxcentre, Room Ba 302, Erasmus Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; f.j.tencate{at}


Background: The Frank–Starling law describes the relation between left ventricular volume and function. However, only a few studies have described the relation between left atrial volume (LAV) and function.

Objective: To describe an LA Frank–Starling law by studying changes in LAV measured by real-time, three-dimensional echocardiography (RT3DE).

Methods: LAV was calculated by RT3DE in 70 patients at end-systole (LAVmax), end-diastole (LAVmin) and pre-atrial contraction (LAVpre-A). According to LAVmax, patients were classified into three groups: LAVmax <50 ml (group I), LAVmax 50–70 ml (group II) and LAVmax >70 ml (group III). Calculated indices of LA pump function were active atrial stroke volume (SV), defined as LAVpre-A – LAVmin, and active atrial emptying fraction (EF), defined as active atrial SV/LAVpre-A ×100%

Results: Active atrial SV was significantly higher in group II than in group I (mean (SD) 19.0 (9.2) vs 8.2 (4.9) ml, p<0.0001), in group III it was non-significantly lower than in group II (16.7 (12.5) vs 19.0 (9.2) ml). Active atrial SV correlated well with LAVpre-A (r = 0.56, p<0.001), but decreased with larger LAVpre-A. Active atrial EF tended to be higher in group II than in group I (43.1 (18.2) vs 33.2 (17.5), p<0.10), in group III it was significantly lower than in group II (26.2 (18.5) vs 43.1 (18.2), p<0.01).

Conclusion: A Frank–Starling mechanism in the left atrium could be described by RT3DE, shown by an increase in LA contractility in response to an increase in LA preload up to a point, beyond which LA contractility decreased.

  • left atrial volume
  • left atrial function
  • Starling mechanism
  • real-time, three-dimensional echocardiography

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  • Conflict of interest: None declared.

  • Abbreviations:
    emptying fraction
    left atrial
    left atrial volume
    real-time, three-dimensional echocardiography
    stroke volume