Int J Cardiovasc Imaging

DOI 10.1007/s10554-017-1160-9

ORIGINAL PAPER

Quantification of left atrial volume and phasic function using

cardiovascular magnetic resonance imaging—comparison
of biplane area-length method and Simpson’s method
Laura Kristin Wandelt1,2   · Johannes Tammo Kowallick1,2 · Andreas Schuster2,3 ·
Rolf Wachter2,3 · Thomas Stümpfig2,4 · Christina Unterberg‑Buchwald1,2,3 ·
Michael Steinmetz2,4 · Christian Oliver Ritter1,2 · Joachim Lotz1,2 · Wieland Staab1,2 

Received: 15 March 2017 / Accepted: 6 May 2017

© Springer Science+Business Media Dordrecht 2017

Abstract  Left atrial (LA) enlargement and dysfunction
are markers of chronic diastolic dysfunction and an impor-
tant predictor of adverse cardiovascular and cerebrovascu-
lar outcomes. Accordingly, accurate quantification of left
atrial volume (LAV) and function is needed. In routine
clinical cardiovascular magnetic resonance (CMR) imag-
ing the biplane area-length method (Bi-ALM) is frequently
applied due to time-saving image acquisition and analysis.
However, given the varying anatomy of the LA we hypoth-
esized that the diagnostic accuracy of the Bi-ALM is not
sufficient and that results would be different from a pre-
cise volumetric assessment of transversal multi-slice cine
images using Simpson’s method. Thirty one patients of the
FIND-AFRANDOMISED-study with status post acute cerebral
ischemia (mean age 70.5 ± 6.2 years) received CMR imag-
ing at 3T. The study protocol included cine SSFP sequences
in standard 2- and 4 CV and a stack of contiguous slices in
transversal orientation. Total, passive and active LA emp-
tying fractions were calculated from LA maximal volume,
minimal volume and volume prior to atrial contraction.
* Laura Kristin Wandelt
laura.wandelt@stud.uni‑goettingen.de
1
Institute for Diagnostic and Interventional Radiology,
University Medical Center Göttingen, Robert‑Koch Straße
40, 37075 Göttingen, Germany
2
German Center for Cardiovascular Research (DZHK),
Partner Site Göttingen, Robert‑Koch Straße 40,
37075 Göttingen, Germany
3
Department of Cardiology and Pneumology, University
Medical Center Göttingen, Robert‑Koch Straße 40,
37075 Göttingen, Germany
4 and cerebrovascular diseases [1, 2]. Studies addressed
Department of Paediatric Cardiology and Intensive
Care Medicine, University Medical Center Göttingen,
Robert‑Koch Straße 40, 37075 Göttingen, Germany
Intra- and inter-observer variability was assessed in ten
patients. Significant differences were found for LA vol-
ume and phasic function. The Bi-ALM significantly under-
estimated LA volume and overestimated LA function in
comparison to Simpson’s method (Bi-ALM vs. Simpson’s
method: ­LAVmax: 80.18 vs. 98.80 ml; L ­ AVpre−ac: 61.09 vs.
80.41 ml; ­LAVmin: 36.85 vs. 52.66 ml; L ­ AEFTotal: 55.17 vs.
47.85%; ­LAEFPassive: 23.96 vs. 19.15%; ­LAEFBooster: 40.87
vs. 35.64%). LA volumetric and functional parameters
were reproducible on an intra- and inter-observer levels for
both methods. Intra-observer agreement for LA function
was better for Simpson’s method (Bi-ALM vs. Simpson’s
method; ICC ­LAEFTotal: 0.84 vs. 0.96; ICC ­LAEFPassive:
0.74 vs. 0.92; ICC L ­ AEFBooster: 0.86 vs. 0.89). The Bi-
ALM is based on geometric assumptions that do not reflect
the complex individual LA geometry. The assessment of
transversal slices covering the left atrium with Simpson’s
method is feasible and might be more suitable for an accu-
rate quantification of LA volume and phasic function.
Keywords  Cardiovascular magnetic resonance imaging ·
Left atrial volume · Left atrial function · Comparison ·
Biplane area-length method · Simpson’s method
Introduction
Left atrial (LA) enlargement and dysfunction repre-
sent important markers of chronic diastolic dysfunc-
tion. Accordingly, quantitative assessment of LA vol-
ume (LAV) and function plays an important role for risk
stratification and prognosis of several cardiovascular
the association of LA enlargement and dysfunction with
the development and maintenance of atrial fibrillation,

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the prediction of pulmonary vein isolation success, first
ischemic stroke, stroke recurrence and the outcome of
patients with acute myocardial infarction [2–9]. Cardio-
vascular magnetic resonance (CMR) imaging allows a
reliable and reproducible application in terms of quanti-
fication of LA volume and function [1]. The evaluation of
standard steady-state free-precession (SSFP) multi-slice
short-axis images using Simpson’s method of disks is
regarded as the common standard for LA volume quan-
tification using CMR [10]. However, the image acquisi-
tion as well as the analysis of multi-slices images and
by association the application of the Simpson’s method
is time-consuming and consequently may be of limited
value in daily clinical routine. Therefore, the biplane
area-length method (Bi-ALM), based on the evaluation
of routinely performed 4- and 2-chamber views, is fre-
quently applied for LA volume and function quantifica-
tion due to timesaving image acquisition and evaluation
[11]. Recent studies focused on the comparability of the
results of the biplane area-length with the standard short-
axis method and basically demonstrated that the biplane-
area length method provides a reliable and reproducible
but also less accurate alternative to the time-consuming
reference standard [11–14]. An alternative approach for
the determination of LA volume and phasic function is
the evaluation of transversal, instead of short-axis, multi-
slice images. Currently, there are no data available that
address the agreement of the biplane area-length method
with the volumetric analysis of multi-slice transversal
images. Thus, this study aimed to analyse the correlation
of two different slice positioning methods and to compare
the results in stroke patients to findings of the literature.
We hypothesized that this approach might generate dif-
ferent results than the previous published comparisons to
the standard short-axis method.
Methods
Patients
A total of 31 subjects (17 women, 14 men, mean age
70.5 ± 6.2 years, range 62–92 years) of the FIND-
AFRANDOMISED-study with status post acute cerebral
ischemia and no history of atrial fibrillation underwent
CMR imaging for the quantification of left atrial vol-
ume and phasic function [15]. The study was performed
according the principles of the declaration of Helsinki
and was approved by the Institutional Review Board. All
patients provided written informed consent before being
included in the study.
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Int J Cardiovasc Imaging
CMR image acquisition
All CMR scans were performed on a 3T MR scanner
(Skyra, Siemens Healthineers, Erlangen, Germany) with
a 32 channel cardiac coil in the supine position. On the
basis of scout images in axial, coronal and sagittal ori-
entations, retrospectively ECG-gated breath-hold steady-
state free-precession (SSFP) cine images were acquired
in the 2- and 4-chamber view with the following prop-
erties: repetition time 41.4  ms, echo time 1.51  ms, flip
angle 53°, field of view 340  mm, matrix size 256 × 256,
slice thickness 6 mm. A stack of contiguous breath-hold
SSFP cine slices with 0 slice spacing was obtained in
transversal orientation with full coverage of both atria
and both ventricles at end expiration. Typical imaging
parameters were: repetition time 48.58  ms, echo time
1.51 ms, flip angle 59°, field of view 340 mm, matrix size
256 × 256, number of slices 25, slice thickness 7 mm.
CMR image analysis
Volumetric analysis was performed offline with commer-
cially available software (QMass MR 7.6, Medis medi-
cal imaging systems, Leiden, The Netherlands). For both
methods LA volumes were assessed at three time-points
of the cardiac cycle: LA maximal volume at left ventricu-
lar end-systole before mitral valve opening (­LAVmax),
LA volume at left ventricular diastole immediately prior
to LA contraction ­(LAVpre−ac) and LA minimal volume
at late left ventricular diastole after LA contraction
­(LAVmin) [16, 17]. ­LAVmax, ­LAVpre−ac and L ­ AVmin were
also normalized to body surface area (BSA) as calcu-
lated by the Mosteller formula [12]. For the biplane area-
length method, semi-automated segmentation of the LA
was performed in the 2- and 4-chamber view. LA vol-
umes were automatically calculated by the software using
the following equation:
0.85 × 4CV Area × 2CV Area
LA volume (LAV) =
Lmin
Lmin corresponds to the shorter long-axis length of the LA
either from the 2-chamber or the 4-chamber view [16, 18].
In the transversal stack, LA endocardial contours were man-
ually traced in each slice and Simpson’s method of disks was
applied for volumetric analysis. This approach is based on
the Simpson’s rule, where the sum of cross-sectional areas
of each slice is applied against the slice thickness and the
interval between the slices [14]. It is not consistently defined
if the left atrial appendage (LAA) must be included in the
measurements of left atrial volume. While some investiga-
tors consider the LAA to be part of the LA volume [19, 20]
Int J Cardiovasc Imaging

other studies exclude the LAA for both methods [12, 14, ICC 0.6–0–74, fair when ICC 0.4–0.59 and weak when
21]. Because of an unreliable detection and differentiation ICC < 0.4 [24, 25].
of the left atrial appendage in the 2-chamber view as well as
in the transversal slices and therefore for a better compara-
bility, we decided to exclude the LAA from the volumetric
measurements in both methods. The pulmonary veins were Results
also excluded in both methods. The left atrial appendage and
the pulmonary veins were excluded in both methods. The CMR examination was feasible in all 31 participants
segmentation of the LA in the transversal stack took about and adequate image quality was obtained in all studies.
15 min whereas the evaluation of the 2- and 4-chamber view Baseline characteristics of the participants are shown in
was distinctly faster (approximately 5  min). Both observ- Table 1. No patient presented with chest wall deformaties,
ers performing the evaluation of the left atria had at least 2 that could have influenced the LA geometry. Exemplary
years of experience in CMR. Total, passive and active LA images of a 2- and 4-chamber view and a stack of transver-
emptying fractions (­LAEFTotal ­LAEFPassive, ­LAEFBooster) sal slices of a participant are shown in Figs. 1 and 2. The
were calculated from the measured LA volumes based on values obtained for LA volumes and phasic functions are
the following equations [16, 22]: presented in Table  2. Statistically significant differences
(p < 0.05) between the two methods were found for LA vol-
ume and phasic function. The biplane area-length method
( )
LAVmax − LAVmin × 100
LAEFTotal =
LAVmax significantly underestimated LA volume and overestimated
( )
LAVmax − LAVpre−ac × 100 LA phasic function compared to the Simpson’s method in
LAEFPassive = transversal slices (Table  2). The highest deviation of the
LAVmax biplane area-length method for LA volume was observed
( )
LAVpre−ac − LAVmin × 100 for ­LAVmin (ml) with an underestimation of 28.2%, the
LAEFBooster =
LAVpre−ac lowest deviation was found for L­ AVmax (ml) with an under-
estimation of 17.9%. For LA phasic function percental
deviation of the biplane area-length method was highest for
Statistical analysis ­LAEFPassive (%) with an overestimation of 35% and lowest
for ­LAEFBooster (%) with an overestimation of 15.4% com-
Statistical analysis was performed using Microsoft Excel pared to the Simpson’s method in transversal slices. Gen-
(Microsoft Corporation, Redmond, WA, USA), Statistica der-specific results are shown in Table 3. There was a trend
version 12 (Dell Inc., Tusla, Oklahoma, USA) and IBM towards higher ­LAVmax, ­LAVpre−ac and ­LAVmin in men than
SPSS Statistics version 24 (IBM Corporation, Armonk, in women for both volumetric techniques.
New York, USA).
All continuous variables are presented as
mean ± standard deviation (SD) unless otherwise noted. Table 1  Patients characteristics (n = 31)
For metric variables, the assumption of a normal distribu-
Mean ± SD
tion was checked graphically by using histograms. In the
case of a skewed distribution, nonparametric tests were Age (years) 70.5 ± 6.2
used. The correspondence of the results for left atrial vol- Gender 17 Female/14 male
ume and function measurements between both methods Height (cm) 168.6 ± 9.5
was determined by Bland–Altman-analyses, Wilcoxon Weight (kg) 82.1 ± 17.1
signed-rank test and Student´s paired t-test [23]. The Body surface area (m²) 2 ± 0.2
main hypothesis was checked in a confirmatory way with Body mass indices (kg/m²) 28.9 ± 5.7
a two-sided type-one error of 5%. For the multiplicity- n = 31
correction the Bonferroni approach was used. In addition,
Hypertension 24
an exploratory evaluation of gender differences for left
Diabetes 3
atrial volume and function was performed using Student´s
Smoking 15
unpaired t-test and Mann–Whitney U test. Intra- and
Hyperlipidemia 10
inter-observer variability for both methods were assessed
Congestive heart failure 1
in ten randomly selected patients with Bland–Altman-
Coronary artery disease 1
analyses and intraclass correlation coefficients (ICC),
Myocardial infarction 2
using a model of absolute agreement. Reproducibility
was considered excellent when ICC > 0.74, good when SD standard deviation

13

Reproducibility
A good (ICC > 0.6) to excellent (ICC > 0.74) agreement
was achieved for intra- and inter-observer measurements of
LA volume and function. Intra- and inter-observer variabil-
ity were slightly better for Simpson’s method than for the
biplane area-length method (Table 4).
Discussion
LA enlargement and dysfunction are known as important
risk factors for adverse cardiovascular and cerebrovascular
Fig. 1  SSFP 2- chamber
view and 4-chamber view of
a 75 year old female patient
showing a representative seg-
mentation of L­ AVmax, ­LAVpre−ac
and ­LAVmin
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Int J Cardiovasc Imaging
events. These include, among others, atrial fibrillation and
ischemic stroke [4, 6, 7]. The aim of the present study
was to compare LA volumes and phasic functions of the
biplane area-length method with the findings of Simpson’s
method of disks in transversal slices in patients with status
post acute cerebral ischemia. In total, 31 CMR scans were
available and LA volume and function were determined in
all participants. The main findings of our study are that the
biplane area-length method significantly underestimated
LA volume ­ (LAVmax, ­LAVpre−ac, ­LAVmin), though sig-
nificantly overestimated LA ejection fraction (­LAEFTotal,
­LAEFPassive, ­LAEFBooster) as compared to the volumetric
analysis of the transversal slices.
Int J Cardiovasc Imaging

Fig. 2  SSFP transversal stack covering the left atrium of a 75 year old female patient showing a representative segmentation of L
­ AVmax (Soft-
ware: QMass MR, Medis)

Table 2  Comparison of Transversal Biplanar Bias ±95% CI p value %

biplane area-length method and
Simpson’s method in transversal Mean ± SD Mean ± SD
slices
LAVmax (ml) 98.80 ± 25.28 80.18 ± 22.91 −18.62 − 26.24 to − 11.01 <0.001 −17.90
LAVmax/BSA (ml/m²) 50.68 ± 12.71 40.87 ± 10.72 −9.81 − 13.77 to − 5.86 <0.001 −17.90
LAVpre−ac (ml) 80.41 ± 23.97 61.09 ± 18.66 −19.31 − 26.65 to − 11.97 <0.001 −22.17
LAVpre−ac/BSA (ml/m²) 41.21 ± 11.94 31.03 ± 8.37 −10.18 − 14.03 to − 6.32 <0.001 −22.17
LAVmin(ml) 52.66 ± 20.48 36.85 ± 15.14 −15.81 − 21.07 to − 10.55 <0.001 −28.19
LAVmin/BSA (ml/m²) 26.93 ± 10.21 18.74 ± 7.40 −8.19 − 10.94 to − 5.44 <0.001 −28.19
LAEFTotal (%) 47.85 ± 7.78 55.17 ± 6.61 7.32 5.18 to 9.45 <0.001 +17.07
LAEFPassive (%) 19.15 ± 6.14 23.96 ± 5.78 4.81 2.73 to 6.90 <0.001 +34.98
LAEFBooster (%) 35.64 ± 6.81 40.87 ± 8.89 5.22 5.22 to 7.66 <0.001 +15.41

For the multiplicity-correction the Bonferroni approach was used

SD standard deviation, CI confidence interval, LAV left atrial volume, LAEF left atrial ejection fraction,
BSA Body surface area

Within the last years, the evaluation of left atrial enlarge-
ment and dysfunction by CMR gained high attention. Pre-
vious studies compared the faster biplane area-length
method with the short-axis method for volumetric analysis
of the left atrium in healthy participants and patients with
cardiovascular diseases as for example patients with atrial
fibrillation as well as patients with coronary artery disease
and systolic LV dysfunction [11–14]. The findings have
been partly different. On the one hand, Nacif et al. showed
that in patients with atrial fibrillation the results of the
biplane area-length method for LA volume (­LAVmax) did
not differ significantly from those obtained by Simpson’s

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 Int J Cardiovasc Imaging

Table 3  Left atrial volume Transversal slices Biplane area-length

and function by gender. Values
are given as mean ± standard Female Male p* Female Male p*
deviation (SD)
LAVmax (ml) 95.03 ± 15.06 103.39 ± 33.97 0.59 74.61 ± 20.02 86.94 ± 25.06 0.20
LAVmax/BSA (ml/m²) 51.25 ± 7.84 49.99 ± 17.20 0.16 40.13 ± 10.24 41.76 ± 11.60 0.74
LAVpre−ac(ml) 77.08 ± 14.06 84.45 ± 32.42 0.77 56.41 ± 15.16 66.78 ± 21.39 0.26
LAVpre−ac/BSA (ml/m²) 41.56 ± 7.27 40.77 ± 16.23 0.26 30.25 ± 7.31 31.98 ± 9.70 0.86
LAVmin (ml) 49.49 ± 13.88 56.50 ± 26.50 0.45 33.73 ± 14.01 40.64 ± 16.09 0.16
LAVmin/BSA (ml/m²) 26.66 ± 7.26 27.26 ± 13.24 0.59 18.09 ± 7.29 19.53 ± 7.74 0.51
LAEFTotal (%) 48.55 ± 7.47 47.01 ± 8.35 0.54 55.94 ± 7.54 54.23 ± 5.38 0.18
LAEFPassive (%) 19.01 ± 5.53 19.32 ± 7.02 0.89 24.20 ± 5.78 23.67 ± 5.99 0.81
LAEFBooster (%) 36.54 ± 7.45 34.56 ± 6.03 0.29 41.70 ± 10.37 39.85 ± 6.94 0.24

LAV left atrial volume; LAEF left atrial ejection fraction, BSA body surface area
*Unadjusted descriptive p-values

Table 4  Reproducibilty of measurements for LA volume and function

(a) Intra-observer variability
Transversal Biplane area-length
Bias (95% CI) ICC Bias (95% CI) ICC

LAVmax (ml) −0.66 (−2.5 to 1.18)
LAVmax/BSA (ml/m²) −0.29 (−1.26 to 0.68)
LAVpre−ac (ml) −0.43 (−2.14 to 1.28)
LAVpre−ac/BSA (ml/m²) −0.17 (−1.06 to 0.71)
LAVmin (ml) 0.31 (−1.08 to 1.7)
LAVmin/BSA (ml/m²) 0.17 (−0.53 to 0.87)
LAEFTotal (%) −0.73 (−2.44 to 0.99)
LAEFPassive (%) −0.38 (−2.2 to 1.45)
LAEFBooster (%) −0.57 (−3.09 to 1.94)
(b) Inter-observer variability
Transversal slices
Bias (95% CI)
0.991 (0.967 to 0.998)
0.994 (0.977 to 0.998)
0.991 (0.968 to 0.998)
0.994 (0.977 to 0.999)
0.994 (0.974 to 0.998)
0.994 (0.978 to 0.999)
0.962 (0.858 to 0.99)
0.916 (0.658 to 0.979)
0.891 (0.564 to 0.973)
ICC
1.34 (−0.76 to 3.44)
0.73 (−0.42 to 1.89)
0.44 (−1.76 to 2.65)
0.31 (−2.05 to 1.43)
−0.31 (−2.05 to 1.43)
−0.06 (−0.96 to 0.84)
0.96 (−1.33 to 3.26)
0.98 (− 2.69 to 4.65)
0.63 (−1.87 to 3.13)
Biplane area-length
Bias (95% CI)
0.994 (0.978 to 0.999)
0.994 (0.976 to 0.999)
0.990 (0.962 to 0.998)
0.989 (0.957 to 0.997)
0.988 (0.953 to 0.997)
0.989 (0.958 to 0.997)
0.837 (0.380 to 0.959)
0.741 (−0.066 to 0.936)
0.856 (0.422 to 0.964)
ICC

LAVmax (ml) −5.39 (−8.36 to − 2.42) 0.962 (0.390 to 0.993) 0.70 (− 2.00 to 3.41) 0.992 (0.971 to 0.998)
LAVmax/BSA (ml/m²) −2.71 (−4.22 to 1.20) 0.974 (0.528 to 0.995) 0.34 (− 1.06 to 1.75) 0.993 (0.971 to 0.998)
LAVpre−ac(ml) −3.52 (−6.13 to − 0.90) 0.972 (0.741 to 0.994) 0.40 (− 2.69 to 3.49) 0.981 (0.925 to 0.995)
LAVpre−ac/BSA (ml/m²) −1.72 (− 2.96 to − 0.49) 0.981 (0.800 to 0.996) 0.23 (−1.38 to 1.85) 0.98 (0.921 to 0.995)
LAVmin (ml) −0.64 (−3.51 to 2.24) 0.976 (0.905 to 0.994) 0.43 (−2.67 to 3.53) 0.966 (0.863 to 0.992)
LAVmin/BSA (ml/m²) −0.29 (−1.72 to 1.15) 0.98 (0.92 to 0.995) 0.32 (−1.24 to 1.89) 0.97 (0.883 to 0.993)
LAEFTotal (%) −2.34 (−5.46 to 0.79) 0.816 (0.317 to 0.953) −0.46 (−4.54 to 3.62) 0.667 (−0.485 to 0.919)
LAEFPassive (%) −1.08 (−3.79 to 1.64) 0.883 (0.554 to 0.971) 0.01 (−2.98 to 3.00) 0.865 (0.432 to 0.967)
LAEFBooster (%) −2.07 (−4.89 to 0.75) 0.824 (0.345 to 0.955) −0.40 (−4.37 to 3.58) 0.734 (−0.163 to 0.935)

CI confidence interval, ICC intraclass correlation coefficient, LAV left atrial volume, LAEF left atrial ejection fraction, BSA Body surface area

method in the short-axis [12]. In contrast, Sievers et  al.
illustrated that the values obtained for ­LAVmax (LA ESV)
and ­LAVmin (LA EDV) by the biplane area-length method
were significantly higher in healthy participants and
patients with atrial fibrillation than those quantified in the
short-axis whereas LA SV and LA EF did not differ signifi-
cantly [11]. Another study in patients with coronary artery
disease and systolic LV dysfunction found no statistically
significant difference between biplane area-length method
and short-axis concerning ­LAVmax (LA ESV). In contrast

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Int J Cardiovasc Imaging
­ AVmin (LA EDV) was significantly underestimated by the
L Our results showed that the two methods cannot be
biplane area-length method and led to a significant overesti-
mation of LA SV and EF [14]. Whilst evidence is mounting
concerning the comparison between the biplane area-length
method and Simpson’s method in the standard short-axis
orientation, little is known regarding the comparability of
the biplane area-length method and Simpson’s method in
transversal slices which offers a further option to quantify
LA volume and phasic function.
To the best of our knowledge, there are also no refer-
ence values available for the evaluation of the LA using
transversal slices in adults. Maceira et  al. published
standard values and reference ranges for LA volumes
­(LAVmax, ­LAVmax/BSA; 120 healthy volunteers from 20
to 80 years) based on the analysis of short-axis images
[1]. We cannot rule out the possibility that the evalu-
ation of transversal slices leads to different results than
the analysis of standard short-axis images. However, our
values for L ­ AVmax and ­LAVmax/BSA are within the ref-
erence ranges of Maceira et  al. Apart from this, refer-
ence values are available for the LA volumetric analysis
by the biplane area-length method. Hudsmith et al. used
this approach for the LA evaluation in 108 healthy volun-
teers (38 ± 12 years). The values we obtained for L ­ AVmax
and ­LAVmin by using the biplane area-length method
are comparable to the results of Hudsmith et al. [19]. At
this point we must note that Hudsmith et al. included the
LAA whereas the LAA was excluded in our study. Unfor-
tunately, we cannot make a statement about L ­ AVpre−ac
as this phasic volume was not investigated in the above-
mentioned studies.
Although LA enlargement is an important risk factor for
stroke, our study collective showed normal values for LAV.
A potential reason for this result could be the small sam-
ple size of our study. However, there is one obvious outlier
for ­LAVmax, ­LAVpre−ac and ­LAVmin at the right lower part
of the corresponding Bland–Altman plots (Fig. 3). In addi-
tion to the increase of the LA volumes, the CMR investiga-
tion displayed a symmetric LV dilatation. Nevertheless, the
evaluation of the LV revealed a normal LV ejection frac-
tion (61%). There were no indications of atrial fibrillation
or hypertension in the patient’s history.
The intra- and inter-oberserver variability showed good
to excellent results for both, transversal slices as well as the
biplane area-length method indicating that both approaches
are reliable and reproducible for the quantification of LA
volume and function. However, the ICC was slightly better
for the evaluation of the transversal slices for both observ-
ers. This might be due to the higher susceptibility of the
biplane area-length method to small variations of the con-
tour determination that result in larger effects on volume
calculation [13].
used interchangeably due to significant and wide variance
for all measured values of the biplane area-length method.
The quantification of LA volume and consequent phasic
function from transversal multislice images is more time-
consuming than the application of the biplane area-length
method but might provide more precise and realistic infor-
mation about the left atrium. Multi-slice evaluation of the
left atrium is renowned as the reference standard as geo-
metrical models are therewith overcome. The biplane area-
length method underlies the geometric assumption of an
ellipsoid chamber that does not reflect the complex and var-
ying geometry of the left atrium. This disadvantage might
be even bigger in cardiac diseases with a pathologically
enlarged atrium. Therefore, we recommend the volumetric
analysis of the transversal slices using Simpson’s method
instead the application of the biplane area-length method.
Limitations
There are some study limitations that could have influenced
our results. Firstly, this study was performed with a rela-
tively small sample size of patients with status post acute
cerebral ischemia and did not include a control group of
healthy volunteers. Secondly, our scan protocol did not
provide the generation of multi-slice images in the short-
axis orientation. Therefore, it was not possible to compare
the volumetric assessment of the transversal slices with the
results of the short-axis as the gold standard for LA quan-
tification. To the best of our knowledge, there are currently
no studies available addressing the difference between
LA volumetric and functional quantification between the
biplane area-length method and the Simpson’s method in
short-axis or transversal orientations with a focus on risk
stratification and/or prediction of adverse cardiovascular
events. Accordingly, this is definitely a topic of interest to
be evaluated in future investigations.
Conclusion
In conclusion, the biplane area-length method leads to
an overestimation of LA volume and underestimation of
LA phasic function if compared to Simpson’s method in
transversal slices. In consequence of the better intra- and
inter-observer variability of the multislice method and
the given fact that the biplane area-length method bases
on geometric assumptions that do not reflect the complex
individual structure of the left atrium, we regard the Simp-
son’s method in transversal slices to be more suitable for
an accurate and realistic quantification of LA volume and
phasic function.
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 Int J Cardiovasc Imaging

Fig. 3  Bland–Altman-plots for the comparison of the biplane area-length method and Simpson’s method

Compliance with ethical standards   Ethical approval  The present study has been approved by the eth-
ics committee and has been performed in accordance with the ethical
standards laid down in the 1964 Declaration of Helsinki and its later
Conflict of interest None.
amendments. All study participants gave their informed consent prior
to their inclusion in the study.

13
Int J Cardiovasc Imaging

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