Simplifying Left Ventricular Function Assessment: The Clinical Value of Mitral Annular Plane Systolic Excursion

Abstract

Background:

Left ventricular (LV) dysfunction is a critical global health concern, usually assessed using parameters such as global longitudinal strain (GLS) and LV ejection fraction (LVEF) by Simpson’s method. However, these methods can be resource-intensive and reliant on high-quality imaging. Mitral annular plane systolic excursion (MAPSE) offers a simpler, more accessible bedside alternative for evaluating LV function.

Objective:

This study explored how MAPSE correlates with key echocardiographic parameters, such as GLS and LVEF, to establish its role as a practical and reliable tool for assessing LV systolic longitudinal function.

Methods:

We conducted a single-center cross-sectional study with 80 patients diagnosed with LV dysfunction (LVEF <50%). Echocardiographic assessments measured were MAPSE, GLS, and LVEF. Statistical analyses examined the relationships between these parameters.

Results:

MAPSE showed a strong correlation with GLS (r = 0.535, P < 0.0001) and a moderate correlation with LVEF (r = 0.324, P < 0.0001). Patients with more severe LV dysfunction (ejection fraction [EF] <40%) had lower mean MAPSE values (11.1 ± 0.4 mm) than those with milder dysfunction (EF >40%, MAPSE 12.4 ± 0.4 mm). MAPSE also correlated inversely with LV filling pressures (E/e’ >14, P < 0.0001) and LV end-systolic dimensions (r = −0.254, P = 0.022). Interestingly, its positive association with tricuspid annular plane systolic excursion (P = 0.0046) highlighted its role in possibly reflecting biventricular function and ventricular interdependence.

Conclusion:

MAPSE is a simple yet powerful tool for assessing LV function, offering strong correlations with GLS and insights into systolic and diastolic performance. Even with suboptimal imaging, its ease of use makes it an invaluable option for cardiac evaluation, particularly in time-sensitive or resource-constrained clinical settings.

INTRODUCTION

Left ventricular (LV) systolic dysfunction (LVSD) remains one of the most significant challenges to cardiovascular health, greatly adding to morbidity and mortality across the globe. Conventionally, the assessment of this condition is traditionally done using measurements like LV ejection fraction (LVEF) by Simpson’s method and global longitudinal strain (GLS). Although these measurements are very informative about heart function, their applicability and accessibility are sometimes limited because they rely on high-quality echocardiograms and sophisticated imaging techniques. In this case, the less complex but still effective alternative is mitral annular plane systolic excursion (MAPSE).

MAPSE measures the longitudinal displacement of the mitral annular plane during LV systole and indirectly represents subendocardial longitudinal fiber function. A normal MAPSE ranges from 12 to 15 mm, and values <8 mm strongly indicate LV dysfunction with an ejection fraction (EF) <50% (sensitivity of 98% and specificity of 82%). Furthermore, a mean MAPSE value of 7 mm has been related to EF <30% with a sensitivity of 92% and specificity of 67%. An EF >55% corresponds to a MAPSE value <10 mm with a specificity of 87% and sensitivity of 90%–92%.[1]

MAPSE would appeal as a sensitive marker of LV longitudinal systolic dysfunction, more so since it can be readily measured even at suboptimal imaging quality. It is also a pragmatic tool for standard use, especially in resource-limited settings.

This study examines the relationship of MAPSE with LVEF by Simpson’s method and GLS in patients presenting with various stages of LVSD. Such relationships may better establish MAPSE as a noninvasive tool for diagnosing and following up patients with LV dysfunction.

METHODS

Study design

We conducted a single-center, cross-sectional study at the Department of Cardiology, Kasturba Medical College, Manipal, for a period of 1 year from August 2023 to August 2024. The study was designed to explore how well MAPSE correlates with LVEF and, particularly, GLS in patients with varying levels of LV dysfunction. Patients included in the study were either newly diagnosed or had a prior diagnosis of LVSD with an LVEF of <50%. All participants provided informed consent after receiving a detailed explanation of the study’s objectives, potential benefits, and associated risks. The inclusion criteria comprised patients with an LVEF of <50%, irrespective of their treatment status, and those willing to provide informed consent. Exclusion criteria included pregnant individuals, patients unwilling to participate, and those with suboptimal echocardiographic imaging windows.

Sample size

The sample size was calculated based on the prevalence of LVSD in the population using the following formula:

where:

• p (anticipated population proportion) =0.30

• d (desired absolute precision) =0.10

• N = finite population size ≈5000

• x (two-sided 95 % confidence interval) =1.96.

We determined the sample size using a finite population correction for proportion estimation. Assuming an approximate population of 5000 patients with LVSD (based on our center’s annual LVSD case volume) and an anticipated prevalence of the outcome of interest of about 30%, we calculated that a sample of roughly 80 patients would provide a 95% confidence level with a 10% margin of error. Accordingly, we aimed to enroll 80 patients in the study. This sample size was deemed sufficient to characterize MAPSE in LV dysfunction with the stated precision.

Data collection and echocardiographic measurements

Echocardiographic assessments were performed for all participants in accordance with internationally accepted guidelines, ensuring consistency through electrocardiographic gating. Key parameters measured included LV dimensions during both systole and diastole and the LVEF, which was calculated using Simpson’s biplane method. GLS was evaluated using speckle-tracking echocardiography, while MAPSE was measured at the lateral mitral annulus using M-mode echocardiography. To measure MAPSE, an apical four-chamber view should be obtained, and M-mode cursor should be positioned through the mitral annulus (usually the lateral side). The distance between the peak (systole) and trough (diastole) of the resulting waveform should be measured, as shown in Figures 1 and 2. Additional parameters assessed included the E/eʹ ratio, the degree of mitral regurgitation, and tricuspid annular plane systolic excursion (TAPSE).

Figure 1.

Apical four-chamber echocardiographic view demonstrating the placement of the M-mode cursor at the lateral mitral annulus. This two-dimensional echocardiographic image shows the apical four-chamber window, with the M-mode cursor line positioned precisely over the lateral mitral annulus. This placement is essential for accurate measurement of mitral annular plane systolic excursion, which reflects longitudinal left ventricular systolic function

Figure 2.

Measurement of mitral annular plane systolic excursion (MAPSE) using M-mode echocardiography. The M-mode cursor is positioned at the lateral mitral annulus in the apical four-chamber view (inset image). The M-mode tracing demonstrates the systolic excursion of the mitral annulus toward the apex during left ventricular systole. The distance between the two calipers on the M-mode tracing represents the MAPSE value, which in this example is 1.05 cm. MAPSE is a simple, reproducible marker of longitudinal left ventricular systolic function. MAPSE = Mitral annular plane systolic excursion

Statistical analysis

Data were recorded in Microsoft Excel and analyzed using GraphPad Prism 9 software (GraphPad Software, Inc., San Diego, CA, USA). Baseline characteristics were summarized using descriptive statistics, while inferential statistics were employed to evaluate correlations and differences. Spearman’s correlation coefficient was used to assess the relationship between MAPSE, LVEF, and GLS. Subgroup analyses were conducted using the Mann–Whitney U test and Dunn’s multiple comparison tests. P < 0.05 was considered statistically significant.

Ethical statement

The study protocol was approved by the Institutional Ethics Committee (Reg. No. IEC: 115/2023) and was registered with the Clinical Trials Registry–India (Reg. No. CTRI/2023/08/056453, Registered on: 14/08/2023). This study was conducted in accordance with the principles of the Declaration of Helsinki after obtaining written consent from the patients. The confidentiality and privacy of all patients were safeguarded throughout the study.

RESULTS

Baseline characteristics

A total of 80 cases were included in the study. The mean age of the patients was 60.17 ± 11.2 years. The study population was predominantly male, 59 males (73.75%) and 21 females (26.25%) [Table 1].

Table 1.

Baseline characteristics

Variables	Frequency, n (%)
Age (years), mean±SD	60.17±11.2
Gender
Male	59 (73.75)
Female	21 (26.25)
Co-morbidities
DM	37 (46.25)
HTN	34 (42.5)
Hypothyroidism	6 (7.5)
Cardiovascular disease
IHD	56 (70)
ACS	45 (56.25)

ACS=Acute coronary syndrome, DM=Diabetes mellitus, HTN=Hypertension, IHD=Ischemic heart disease, SD=Standard deviation

Correlation of mitral annular plane systolic excursion with echocardiographic parameters

Correlation analysis revealed significant positive associations between MAPSE and various echocardiographic parameters, including LVEF by Simpson’s method, M-mode EF, and GLS. The adjusted P values for all correlations were <0.0001, indicating strong statistical significance. When comparing the strength of correlations, GLS showed the strongest association with MAPSE (r = 0.5350, P < 0.0001) [Figure 3]. The mean MAPSE value in the group with LV dysfunction was found to be 11.1 ± 0.4 mm.

Figure 3.

Correlation of mitral annular plane systolic excursion (MAPSE) with echocardiographic parameters. Correlation of global longitudinal strain with MAPSE (r = 0.5350) is stronger than AL ejection fraction with MAPSE (r = 0.3249, P < 0.0001). LVEF = Left ventricular ejection fraction, GLS = Global longitudinal strain, MAPSE = Mitral annular plane systolic excursion

Left ventricular dysfunction and mitral annular plane systolic excursion

Patients were divided into mild LV dysfunction (EF >40%) and moderate-severe LV dysfunction group (EF <40%). Patients with mild LV dysfunction (EF >40%) (r = 0.3297) and moderate-to-severe LV dysfunction (EF <40%) (r = 0.2063) both demonstrated statistically significant correlations with MAPSE (P < 0.001). The mean MAPSE value was higher in the mild LV dysfunction group (12.4 ± 0.4 mm) compared to the moderate-to-severe LV dysfunction group (11.1 ± 0.4 mm) [Figures 4 and 5]. However, number in each group was inadequate to make robust conclusions.

Figure 4.

Correlation between mitral annular plane systolic excursion and ejection fraction >40% (r = 0.3297, P < 0.001). EF = Ejection fraction, MAPSE = Mitral annular plane systolic excursion

Figure 5.

Correlation between mitral annular plane systolic excursion and ejection fraction <40% (r = 0.2063, P < 0.001). EF = Ejection fraction, MAPSE = Mitral annular plane systolic excursion

Elevated left ventricular filling pressures and mitral annular plane systolic excursion

Elevated LV filling pressures (E/E’ >14) inversely correlated with MAPSE (r = −0.1268, P < 0.0001), with higher E/E’ values corresponding to lower MAPSE values. This indicates that in patients with elevated LV filling pressures, MAPSE values were lower, with a mean value of 10.5 ± 0.4 mm [Figure 6].

Figure 6.

Graph showing the correlation between mitral annular plane systolic excursion and mean E/e’ (r = −0.1268, P < 0.0001). MAPSE = Mitral annular plane systolic excursion

Relationship of mitral annular plane systolic excursion with left ventricular end systolic dimension

MAPSE showed a significant negative correlation with LV end-systolic dimension (LVESD; r = −0.2543, P = 0.022). This relationship indicates that smaller LVESD values were associated with higher MAPSE. This indirectly meant LV dysfunction causing LV dilatation would indirectly have lower MAPSE values, with a mean value of 11.5 ± 0.4 mm [Figure 7].

Figure 7.

Relation of left ventricular end-systolic dimension with mitral annular plane systolic excursion (r = −0.25, P = 0.022). MAPSE = Mitral annular plane systolic excursion, LVESD = Left ventricular end-systolic dimension

Relationship of mitral annular plane systolic excursion with tricuspid annular plane systolic excursion

A positive correlation was observed between MAPSE and TAPSE (P = 0.0046), demonstrating that reductions in MAPSE were accompanied by reductions in TAPSE, which could have been possibly due to ventricular interdependence and myofibrillary arrangement of the fibers.

DISCUSSION

This study provides evidence that MAPSE is an easy and valid measure of cardiac function. Further, by assessing its relationship to other established echocardiographic parameters, it has been found that MAPSE can be an easy and efficient tool for the assessment of LV function in different clinical settings.

Mitral annular plane systolic excursion and its relationship with global longitudinal strain and ejection fraction by Simpson’s method

One of the most significant findings of this study is the strong positive correlation that exists between MAPSE and GLS. In fact, it was noted that this relationship does indicate that MAPSE is a reliable marker of longitudinal myocardial function. However, GLS remains the gold standard, which is often associated with high-quality imaging and expensive equipment. MAPSE, on the other hand, is much easier and quicker to measure, making it an attractive alternative, particularly in situations where time or resources are limited. A related study was conducted by Hamza et al.[2] for the prediction of subclinical LVSD by MAPSE in M-mode echo in correlation to speckle tracking by two-dimensional echo and tissue Doppler imaging in patients with type 2 diabetes mellitus (DM). The study included 100 asymptomatic patients with type 2 DM and concluded that MAPSE was significantly lower in the DM group and also had a linearly positive correlation with EF, GLS, and systolic annular velocity (Sa) wave (r = 0.56, 0.72, 0.59).

MAPSE also showed a positive correlation with LVEF, as measured by Simpson’s method. An observational study was conducted by Balasubramaniyan et al.[3] for validating MAPSE to assess LV function. According to the study, MAPSE and EF by Simpson’s method had a positive correlation.

Although this correlation was not as strong as with GLS, it still underscores MAPSE’s ability to reflect LV systolic function. Another study of the correlation of MAPSE with LV GLS in patients undergoing coronary artery bypass grafting (CABG) was conducted by Borde et al.,[4] which included 51 patients who underwent CABG and revealed a strong positive correlation between MAPSE and GLS (r = 0.83, P < 0.0005), indicating a strong statistical significance.

These findings reinforce the idea that MAPSE can complement traditional measures such as GLS and LVEF, offering valuable insights even in emergency settings and when ideal imaging conditions are not available.

Mitral annular plane systolic excursion in varying degrees of left ventricular dysfunction

We could postulate that MAPSE is sensitive enough to differentiate between varying degrees of LV dysfunction. Our study observed that in cases of mild LV dysfunction (EF >40%), patients exhibited a higher mean MAPSE value of 12.4 ± 0.4 mm compared to those with severe LV dysfunction (EF <40%), who had a mean MAPSE of 11.1 ± 0.4 mm. The sensitivity to differentiate among different levels of dysfunction can be considered useful in stratifying LV dysfunction based on MAPSE. This could assist the clinicians in selecting those patients who would require closer follow-up or more aggressive treatment. However, this subgroup analysis may be underpowered due to the small sample size of the study.

Mitral annular plane systolic excursion and left ventricular filling pressures

Another important finding was the inverse relationship between MAPSE and LV filling pressures (E/E’ >14). Elevated filling pressures indicate diastolic dysfunction. The strong correlation suggests that MAPSE could be used as a versatile parameter for assessing overall systolic and diastolic dysfunction. A study was conducted along these lines by Hernandez-Suarez et al.[5] to assess MAPSE in patients with LV diastolic dysfunction, highlighting the importance of age and LV measures in computing MAPSE in patients with diastolic dysfunction. Based on age and LVEF, a condensed model was put forth to forecast the MAPSE. It was also postulated that high LV filling pressures generated by the left atrium restrict the net ascent of the mitral annulus, thus diminishing its net descent.

Mitral annular plane systolic excursion and left ventricular end-systolic dimension

We also observed that MAPSE was negatively correlated with LVESD. As the LV dilates and its efficiency declines, MAPSE values tend to decrease. Further research in this area is needed to expand on these observations and confirm their implications.

Interestingly, MAPSE also correlated positively with TAPSE, an index of right heart function. The plausible explanation could be ventricular interdependence and the arrangement of myofibrillary fibers. MAPSE’s ability to reflect these dynamics makes it a valuable tool for comprehensive cardiac assessments.

The simplicity and practicality of MAPSE stand out as its biggest strengths. Unlike GLS or Simpson’s method, which can be time-consuming or require high-quality images, MAPSE is quick to measure and less dependent on image quality. This is especially useful in emergency conditions or resource-poor environments because it offers valuable information on both systolic and diastolic function, thus empowering clinical decision-making and timely therapies.

Limitations and future directions

There are a few caveats with the findings above. Our sample size was small and it was a single-center study, thus the results of this study may not be generalizable. This means our results might not fully reflect the challenges of real-world practice. This study also did not assess the impact of wall motion abnormalities on MAPSE and its value in ischemic versus nonischemic cardiomyopathy has to be studied further. We have excluded patients with arrhythmias, and evaluation by MAPSE has to be studied further in this group. Numbers are not significant enough for multivariate regression analysis to predict if the benefit of MAPSE is independent of GLS and area length-derived LVEF. Subgroup analysis will be underpowered due to the small sample size.

CONCLUSION

This study highlights MAPSE as a dependable and versatile tool for assessing LV function. It showed strong correlations with other measures like LVEF by Simpson’s method and GLS, with an especially strong link to GLS, making it an excellent indicator of longitudinal heart function. MAPSE stands out for its simplicity and ability to deliver accurate results even with suboptimal imaging, making it especially useful for patients with conditions such as obesity or chronic lung disease. Its correlation to elevated LV filling pressures needs further studies to assess its role in evaluating diastolic dysfunction. Future studies should focus on larger, more diverse populations, including multicenter studies and prospective cohorts, and investigate how MAPSE performs over time or predicts long-term outcomes like heart failure hospitalizations and mortality.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.