Cas du 18/03/15 : MAPSE

Presentation: A patient had this echo loop.

#1: What is wall motion of the anterolateral wall?

#2: Is there diastolic dysfunction?


















Explanation: The lateral wall cannot be visualized so the wall motion cannot be directly interpreted.  However, indirect interpretation via mitral annular plane systolic excursion (MAPSE) can be predictive of left ventricular ejection fraction.  If the MAPSE is < 12 mm the LVEF is most likely less than 50%.  However, Tissue Doppler appears to be more accurate. MAPSE by M Mode does have correlation with diastolic parameters such as Tissue Doppler peak systolic annular velocity in healthy individuals but there is not effective concordance and cannot be used in place of Tissue Doppler measurements.

In this loop the lateral wall cannot be interpreted, but, given that the septal wall is hypokinetic, the apex is akinetic and the MAPSE appears less than 12 mm, we could estimate that the ejection fraction is less than 50% and the lateral wall is most likely not normal.  MAPSE does not indicate the diastolic dysfunction of the left ventricle.

Further reading:

http://ehjcimaging.oxfordjournals.org/content/7/3/187.long

Mitral annular motion as a surrogate for left ventricular function: Correlation with brain natriuretic peptide levels

Results MAPSE < 12 mm determined by MME has 90% sensitivity, 88% specificity & 89% accuracy for detection of LVEF <50%, while these values were 94%, 93% & 94% respectively for (Sm) < 8 cm/s determined by PWDTI. BNP level >75 pg/ml has 98% sensitivity, 90% specificity & 97% accuracy for detection of LV Dys either (S,D, or both). BNP levels were significantly higher in patients with combined (S & D) Dys. Than those with only (S) Dys, the later group had significantly higher BNP levels than those with only (D) Dys. (1054.5 ± 202.3 pg/ml vs. 500 ± 39.9 pg/ml & 500 ± 39.9 pg/ml vs. 215.3 ± 100.9 pg/ml respectively, P < 0.001) & each were significantly higher than control group (12.3 ± 5.7 pg/ml, P < 0.001). Significant correlations (P < 0.001 for all) were found between BNP levels and Em (r =−0.82), Sm (r=−0.7), early transmitral (E) to Em ratio (r=0.61), MAPSE (r=−0.54), LVEF(r=−0.64) & LV end D dimension (r=0.63).

Conclusion MME and PWDTI used for assessment of MAM are useful methods for evaluation of LV function but parameters measured by PWDTI correlate more strongly with plasma BNP levels than those measured by MME and provide a simple, sensitive, accurate and reproducible tool for early diagnosis of LV dysfunction.

http://www.cardiovascularultrasound.com/content/11/1/16#B12

Mitral annular plane systolic excursion (MAPSE) in shock: a valuable echocardiographic parameter in intensive care patients

Compared to survivors, non-survivors had a significantly lower MAPSE (8 [IQR 7.5-11] versus 11 [IQR 8.9-13] mm; p= 0.028). Other univariate predictors were age (p=0.033), hsTNT (p=0.014) and Sequential Organ Failure Assessment (SOFA) scores (p=0.007). By multivariate analysis MAPSE (OR 0.6 (95% CI 0.5- 0.9), p= 0.015) and SOFA score (OR 1.6 (95% CI 1.1- 2.3), p= 0.018) were identified as independent predictors of mortality. Daily measurements showed that MAPSE, as sole echocardiographic marker, was significantly lower in most days in non-survivors (p<0.05 at day 1–2, 4–6).

Conclusions

MAPSE seemed to reflect LV systolic and diastolic function as well as myocardial injury in critically ill patients with shock. The combination of MAPSE and SOFA added to the predictive value for 28-day mortality. 

http://ehjcimaging.oxfordjournals.org/content/14/3/205

Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease

MAPSE and ejection fraction

The average normal value of MAPSE derived from previous studies for the four annular regions (septal, anterior, lateral, and posterior) ranged between 12 and 15 mm^3,14 and a value of MAPSE <8 mm was associated with a depressed LV EF (<50%) with a specificity of 82% and a sensitivity of 98%.³ 

A mean value for MAPSE of ≥10 mm was linked with preserved EF (≥55%) with a sensitivity of 90–92% and a specificity of 87%.^16,19 In addition, a mean value for MAPSE of <7 mm could be used to detect an EF <30% with a sensitivity of 92% and a specificity of 67% in dilated cardiomyopathy patients with severe congestive heart failure.¹⁴ 

It is of note that the association between MAPSE and EF is only valid in case of normal or dilated left ventricles,^20,21 while the correlation is rather poor in patients with LV hypertrophy.

Hypertensive heart disease

The impairment in the contractile function of LV longitudinal fibres may substantially precede that of LV circumferential fibres in patients with hypertension because of LV hypertrophy, geometry, and wall stress.⁵ This might explain the ‘early’ reduced longitudinal function (= MAPSE) in contrast to the long time preserved circumferential and radial function (= EF). Thus, reduced MAPSE can be used as a sensitive early marker of LV systolic dysfunction in hypertensive patients.⁴⁸
 

Coronary artery disease

Willenheimer et al.⁵⁵ demonstrated that MAPSE was reduced in 88 out of 1350 consecutive patients with visual evaluated normal LV regional wall motion and these patients with reduced MAPSE had either prior myocardial infarction (60%) or coronary artery disease without infarction (33%), or uncontrolled hypertension (2%) while definitive evidence for cardiovascular diseases was absent in only 4% patients with reduced MAPSE. This suggests that decreased MAPSE, in the case of normal LV regional wall motion, could serve as a echocardiographic functional sign for myocardial abnormalities, predominantly indicating subendocardial dysfunction.⁵⁵

Aortic stenosis

^{MAPSE could be used as a predictor of long-term prognosis for patients receiving aortic valve replacement operation and MAPSE >7 mm is linked with satisfactory functional improvement after aortic valve replacement. 
In the clinical setting, it is sometimes difficult to distinguish between moderate AS with low gradient and severe AS with low gradient due to reduced stroke volume. A recent study found that MAPSE was useful to distinguish between these two entities.57 In patients with an isolated low-gradient AS, a cut-off value of MAPSE <9 mm had an excellent sensitivity (100%) and specificity (100%) to distinguish between moderate and severe AS .}

Implication for prognosis and therapy

MAPSE is of prognostic importance in the risk stratification for patients with atrial fibrillation,⁶¹ patients post-myocardial infarction,⁶² and patients with heart failure.^15,63,64 Cardiac mortality was 44% in atrial fibrillation patients with an MAPSE <7 mm during 45 months follow-up.⁶¹ In post-myocardial infarction patients with MAPSE <8 mm, the combined mortality/hospitalization incidence was 43.8%.⁶² Sveälv et al.⁶⁴ showed that 10 years survival was significantly better in heart failure patients with highest MAPSE (>9 mm) than in heart failure patients with the lowest MAPSE (<5 mm) (Figure 5). Interestingly, significant correlation was found between serum BNP levels and MAPSE (r = −0.54, P < 0.001).³¹

Limitation of MAPSE

Some of the variations of MAPSE are due to cardiac size. Theoretically, this means that the annular displacement should be normalized for heart size. This is definitely necessary in children, where the variation in cardiac size is great. 

The interpretation of MAPSE should be carefully applied in case of a mobile apex, such as large pericardial effusion. Also in patients with paradox septal motion, because of severe right heart dysfunction, septal MAPSE is not only reflecting LV function but rather RV abnormalities. Thus in these patients, the lateral MAPSE should be used. It is to be mentioned that MAPSE, as opposed to global longitudinal systolic strain assessment, cannot detect regional areas of dysfunction.

After cardiac surgery, septal MAPSE, together with RV function, might be more reduced compared with lateral MAPSE.

Sometimes in patients with mitral valve disease, the mitral ring is extremely calcified. In these patients, the direct MAPSE measurement at the mitral ring is not possible and longitudinal functional assessment should be done slightly more above in the myocardium.

Another limitation of this parameter is that small localized abnormalities (i.e. small areas of fibrosis) cannot be detected as it is only possible to assess longitudinal function of the complete wall.