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ECG suggests LAE . . . Echo reveals an absolutely normal Left atrium . . . what is your comment ?

Posted Feb 08 2013 12:00am

This is an ECG of a 42 year old man .He was reported as  Left atrial  enlargement (LAE) and was referred for  echocardiography . His echo was normal . LA measured 2.5 X 3.1 cm .The consultant  called back the echo lab ,  to verify   the left atrial dimension .He thought he was very sure of LAE .It took  considerable time to convince him about the credibility  of the echocardiographer . He was  right after all  . . . still . . .  ECG was  also looked  convincing  for LAE !

left atrial  enlargement by ecg limitations sensitivity

left atrial  enlargement by ecg limitations sensitivity  echo la dimension

                         Is this phenomenon  of wide P wave with normal atrial dimension  common ?

Yes it is . It  underscores  poor sensitivity of ECG in the  diagnosis  of LAE .The P wave abnormality in the above patient is due to Inter atrial block (IAB ) . This widens the p wave .

What  are the types of Inter atrial block ?

inter atrial block europace 1999 de luna


P wave widening is not synonymous with LAE .(Here P waves  widened   due to sluggish inter nodal pathway and inter atrial pathway .It is something like QRS widening in  bundle branch blocks  )

Final message

IAB is an important differential diagnosis for LAE . The significance of which is not entirely clear . It  is possible  IAB   precede LA enlargement  .It can even trigger AF due to  inhomogeneity.

Even though IAB was reported in 1950s  (Puech P* ) ,  it was  rarely  considered important With  increasing incidence of atrial arrhythmia in aging population , IAB is expected to  come into the lime- light again . The sophisticated electro anatomical mapping  can unravel the mysteries surrounding this entity .



*Puech P. L’activite´ electrique auriculaire normale et pathologuique. Paris: Masson, 1956; 206.

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