Mitral annular plane systolic excursion as a single measure for the non-invasive assessment of left ventricular filling pressures

Left atrial reservoir strain (LASr) provides diagnostic and prognostic value in patients with heart failure and demonstrates a superior correlation with left ventricular filling pressure compared to other echocardiographic parameters. However, LASr may present technical challenges and may not be accessible to all clinical echocardiographers. Given that LASr results from left atrial stretch during apical descent of the mitral annulus, mitral annular plane systolic excursion(MAPSE) may offer comparable diagnostic value to LASr .Purposes: To examine the relationship between MAPSE and LASr and assess the diagnostic performance of MAPSE in identifying patients with elevated left ventricular end-diastolic pressure (LVEDP).

We conducted a study on stable patients who underwent same-day echocardiography and invasive left-heart catheterization. MAPSE was obtained from the lateral and septal annulus using M-mode imaging, and the average of both measurements was calculated. The echocardiographer was blinded to invasive pressure data. An LVEDP value >16 mmHg was defined as elevated Left Ventricular filling pressure. The exclusion criteria were: patients without sinus rhythm, left prosthetic valve, severe mitral and aortic insufficiency, moderate or severe aortic stenosis, mitral stenosis of any severity, severe calcification of the mitral annulus, and patients with acute myocardial infarction referred for primary PCI.

The study included 61 patients. The median age was 56 (52-61). The median ejection fraction was 56.6% (40.4-60). The median MAPSE was 1.1 cm (0.85-1.35). The mean LASr and LVEDP were 28.3% (±9.71) and 17.8 mmHg (±6.14) respectively. The correlation of MAPSE with LASr was r=0.84 (p=<0.001)( Fig. 1A ), the correlation between LASr and LVEDP r= -0.43 (p <0.001)( Fig. 1B) and between MAPSE and LVEDP r= -0.53 (p=< 0.001)(Fig 1C). Additionally, MAPSE exhibited a strong correlation with the global longitudinal strain of the left ventricle (r=0.76; p=<0.001)(Fig 1D). The MAPSE area under the curve for the prediction of elevated left ventricular filling pressure was 0.84, and the same for LASr was 0.75 (p=0.026 vs MAPSE). Left atrial volume presented an area under the curve of 0.71 (p= 0.039 vs MAPSE) and E/e' ratio 0.67 (p=0.008 vs MAPSE)(Fig 2). According to ROC analysis, the optimal cut-off to differentiate between normal and elevated left ventricular filling pressure was 1.2 cm, with a sensitivity of 90% and specificity of 71%. The optimal cut-off point of LASr was 29.5% with a sensitivity of 79% and a specificity of 63%. The cut-off point of ratio E/e'>14 had a sensitivity of 24% and a specificity of 85%.

This investigation showed that MAPSE is a parameter exhibiting adequate correlation with LVEDP, demonstrating superior sensitivity and specificity compared to LASr and other commonly utilized parameters for the non-invasive prediction of elevated left ventricular filling pressure.FIGURE 1FIGURE 2