European Journal of Cardiovascular Medicine

Heart failure (HF) occurs from structural or functional abnormalities of the heart, particularly affecting the left ventricle (LV) which is the result of changes in LV geometry and mechanics. There are various causes of heart failure, the most common being coronary artery disease, other causes includes hypertension, cardiomyopathies, inflammatory and metabolic disorders. In HF, the myocardium undergoes pathological changes that result in altered mechanical properties. These changes include fibrosis, myocyte hypertrophy, and altered extracellular matrix composition, leading to reduced myocardial compliance and contractility which can be assessed by various non-invasive imaging like echocardiography.¹

Accurate assessment of LV function is critical for diagnosing heart failure, guiding therapeutic interventions, and predicting patient outcomes. These assessments help clinicians identify the severity of heart failure, monitor disease progression, and tailor treatment strategies to improve patient prognosis.²

Mitral annular plane systolic excursion (MAPSE) measures the movement of the mitral annulus towards the apex during the ventricular systole and is a simple yet effective parameter for evaluating longitudinal LV function. Reduced MAPSE values are associated with impaired LV function and worse clinical outcomes in heart failure patients.3 Global Longitudinal Strain (GLS) is a measurement to assess the squeezing ability of LV. It specifically looks at how much the LV shortens from its base towards the apex.4 GLS can detect subtle changes in heart function even before traditional measures like ejection fraction (EF) which makes it a valuable tool for identifying people at risk of heart problems before symptoms develop.

Our hypothesis proposed that expressing MAPSE as a percentage of the LV long axis shortening (MAPSE/L) could serve as a more practical echocardiographic parameter for heart failure patients. Recognizing GLS as a well-established measure of cardiac function, we also assessed the correlation between MAPSE/L and GLS in heart failure patients.5 this study aimed to determine the potential of MAPSE/L as a marker of cardiac function, especially in comparison to GLS. Our aim is to assess the LV systolic function using MAPSE/L and GLS in heart failure patients and to find correlation between MAPSE/L and GLS in patients with heart failure.

This prospective observational study on assessment of left ventricular function using MAPSE/L and GLS in heart failure patients was done from December 2023 to June 2024. 42 consecutive patients, who presented to outpatient department and intensive care unit, with LV dysfunction were included in the study and assessed. MAPSE, End diastolic length (EDL), Ejection fraction (EF) MAPSE/L and GLS were measured.

All adult patients coming for echocardiography with age >18 years with LV dysfunction were included. Patients with arrhythmias, parturients, poor echo window and psychiatric illness were excluded.

By using ECG gated 2D echocardiography, M-mode, speckle tracking technique (Philips affinity 50C machine), the standard parasternal long axis (PLAX), parasternal short axis (PSAX), Apical 4 chamber (A4C), Apical 2 chamber (A2C), Apical 3 chamber (A3C) and Subcostal view was recorded. The LV systolic Function was assessed by modified Simpson’s Biplane method for EF, GLS and MAPSE.

MAPSE was measured using M-mode in the A4C view by identifying the mitral annular plane, by referencing the movements of both the lateral and septal walls of the left ventricle. The displacement of the plane relative to the ventricular apex was measured. The M-mode image was positioned perpendicular to the identified mitral annular plane for optimal accuracy. The displacement between the lowest point in early diastole and the highest point during systole was measured. This measurement was typically performed on both the septal and lateral walls of the mitral annulus, and the final MAPSE value is obtained by averaging these two measurements. At end-diastole, the left ventricular length (L) is measured as the straight line distance between the lateral edge of the mitral annulus and LV apex.6

Simpson's Rule is a volumetric technique, typically utilizes images acquired in either the A4C or the A2C view. The disc segmentation was measured virtually in the LV cavity, surface area is calculated based on its dimensions and volume summation of all the individual discs up to obtain the total volume of the left ventricle was done.

The GLS was obtained from ECG-gated A4C, A2Cand A3C, echocardiographic views. Image was selected and ACMQ (cardiac motion) application was used. Specific AVC gated ECG cine loop was selected. Respective A4C, A2C, A3C GLS strain pattern were chosen. The in-built software automatically generated an initial region automated Region of Interest (ROI) which encompassed the entire thickness of the LV myocardium. To ensure optimal tracking accuracy, a trained technician further refined the automatically generated ROI. Following successful tracking, the LV longitudinal strain was subsequently divided and displayed for seven distinct myocardial segments. The GLS representing the overall LV shortening was then calculated by averaging the strain values obtained from all seven segments. The GLS grading are as follows: Normal: -15 to 25, mildly reduced: -15 to -12.5, moderately reduced: -12.5 to -8.1 and severely reduced: < -8.7

The data was entered in a predesigned Excel Sheet, and statistical analysis was done using Statistical Package for the Social Sciences (International Business Machines Corporation (IBM), New York), Version 26.0. The distributions of categorical variables like age, gender, severity of LV dysfunction and GLS between the groups were expressed in frequency and percentage. The comparison of these categorical variables between the groups was carried out by using the Chi-square test/ Fisher's test. The distribution of continuous and discrete variable like MAPSE and MAPSE/L was expressed in terms of mean with standard deviation or median with interquartile range based on the data distribution. They were compared using an independent student's t-test or Mann-Whitney test. Pearson correlation co- efficient was used to find the correlation between MAPSE/L and GLS along with coefficient of determination to predict the outcome of the same. The significance level for all the analyses was set at less than 0.05

In this study, 42 patients who had diagnosed to have heart failure, who attended cardiac OPD, cardiac ICU was included in the study. Among 42 patients, 83.3 % patients were male and 16.7% patients were female. Out of which, 42.9% belong between 51-60 years, 19.2% between 35-50 years and 38.1% more than 60 years. 40.5% patients had Mild LV function, 38.1 % had Moderate LV dysfunction and 21.4% had Severe LV dysfunction. (Table. 1)

Table.1. Demographic data distribution (N =42)

Data represents age and their respective percentages.

Among patient population 25 patients (59.5%) had MAPSE in the range of 0.8-1.2 cm and 7 patients had MAPSE <0.8 cm and 10 patients had MAPSE >0.8 cm. Figure 1 represents the MAPSE data among the patients. Average MAPSE/L (Mitral annular plane systolic excursion/ Diastolic length) was 0.13±0.03 (Table 2)

Figure.1. MAPSE (Mitral annular plane systolic excursion) among pa

Table.2. MAPSE and MAPSE/ L among patient population (N = 42)

Table compares average mean of MAPSE/L with various range of MAPSE. Among our study population, 7 patients (<16.7%) had GLS < -10%, 29 patients (69%) had GLS of -10 to 16%, and 6 patients (14.3%) had GLS of > -16%. Figure 2 represents the GLS data among the patients.

Figure.2. Global longitudinal strain (GLS) among the study participants

Both MAPSE/L and MAPSE was analysed by Pearson correlation coefficient. MAPSE/L demonstrated a strong correlation with GLS (correlation coefficient: 0.778, p < 0.001). Similarly, MAPSE alone showed a strong correlation with GLS (correlation coefficient: 0.80, p < 0.001). Also, EF also correlated well with GLS (correlation coefficient: 0.70, p < 0.001) (Table 3). Coefficient of determination is used to predict the outcome and was found to predict the outcome of LV systolic dysfunction. Figure 3 represent the scatter plot to show the correlation between GLS and MAPSE/L.

Figure.3. Scatter plot correlation between Global longitudinal strain and MAPSE/L

(N=42)

Table.3. Correlation between MAPSE/L and GLS among study participants (N=42)

*The correlation is analysed by Pearson correlation coefficient

The concept of Mitral Annular Plane Systolic Excursion (MAPSE) was initially introduced by Hamilton and Rompf in 1932. They described it as the caudal- cephalad motion of the atrioventricular plane. MAPSE has emerged as a dependable and consistent indicator of the longitudinal function of the left ventricle (LV). Studies have shown a strong correlation between MAPSE and Left Ventricular Ejection Fraction (LVEF), with reported correlation coefficients (r) ranging from

0.55 to 0.95.8

Recent literature review suggests that MAPSE correlates well with GLS, providing a reliable alternative for evaluating LV longitudinal function in routine clinical practice, especially in patients in myocardial failure.9

Studies using 2-D and 3-D models to demonstrate myocardial strain using various imaging modalities had revealed that reduced MAPSE was associated with decreased GLS, emphasizing that both parameters reflect similar aspects of myocardial dysfunction.10

Precision models done using multi-parametric Magnetic Resonance cardiac imaging also confirmed that in patients with heart failure with dilated cardiomyopathy with preserved ejection fraction (HFpEF) that both MAPSE and GLS were depressed, highlighting their utility in detecting early myocardial dysfunction.11

Interestingly, MAPSE has demonstrated comparable efficacy to Global Longitudinal Strain (GLS) in identifying early LV dysfunction. This finding aligns with previous research indicating a positive relationship between MAPSE and (GLS) longitudinal strain measurements.12, 13 Our study also found a good correlation between MAPSE with LVLS. In a study focused on employing MAPSE lat (Mitral Annular Plane Systolic Excursion lateral) normalized by left ventricular length (MAPSE/L) as an indicator of left ventricular (LV) longitudinal function in a group of children, where accounting for age-related changes in ventricular length is essential, and researchers discovered a moderate correlation between Global Longitudinal Strain (GLS) and MAPSE lat/L.5

To measure GLS, we need good echo images, so we may not be able to get accurate GLS at all times. In our study both MAPSE and MAPSE/L demonstrated very strong correlation with GLS. We assumed that LV length may vary among genders and patients with heart failure, so LV length may affect MAPSE value. We also demonstrated the average MAPSE/L values were 0.13±0.03 among patients. In patients with MAPSE of <0.8cm, 0.8 -1.2 cm, >1.2 cm, the average MAPSE/L was 0.08±0.01, 0.13±0.01, 0.17±0.02 respectively. MAPSE/L had good correlation with GLS at different ranges of MAPSE. So MAPSE/L can be a useful indicator in assessing LV function.

Our study involving heart failure patients has demonstrated a strong correlation between MAPSE/L and GLS which suggests that both methods provide comparable information about the LV's longitudinal systolic function. Despite the growing adoption of sophisticated echocardiographic techniques, the MAPSE/L ratio is expected to remain a valuable and straightforward parameter for assessing LV

longitudinal systolic function during routine echocardiographic examinations. This is due to its simplicity and wide availability.

LIMITATIONS:

Variability between vendors poses a significant challenge in strain measurements, potentially impacting the reliability of prediction models. Even within the same vendor, disparities in speckle-tracking software versions can result in varying GLS values. It is also essential to note that MAPSE/L does not assess segmental LV function, limiting its ability to represent overall LV function in individuals with localized myocardial issues. Additionally, the assessment of MAPSE/L does not consider the translational motion of the entire heart. This limitation is particularly relevant in cases involving a mobile apex, such as those with substantial pericardial effusion, where caution is warranted in interpreting MAPSE/L values.

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