What is mitral annular plane systolic excursion (MAPSE) and how is it used to assess left ventricular function?

Mitral Annular Plane Systolic Excursion (MAPSE)

MAPSE is a simple M-mode echocardiographic measurement of the longitudinal systolic excursion of the mitral annulus toward the left ventricular apex during systole, serving as a reliable marker of left ventricular longitudinal systolic function that can detect myocardial dysfunction even when ejection fraction remains normal.

Definition and Measurement Technique

MAPSE measures the distance the mitral annulus moves toward the LV apex during systole, reflecting the longitudinal contraction of the left ventricle. According to the 2016 ASE/EACVI guidelines, MAPSE is acquired from the apical 4-chamber view using M-mode or 2D imaging, measuring the systolic excursion of the lateral (or medial) mitral annulus 1.

Normal Reference Values

The guidelines provide age-specific normal values 2:

• Term neonates: >8 mm (range 8-11 mm)
• Children: Z-scores available; generally >12 mm (12-17 mm)
• Adults: Lateral annulus ≥12-14 mm
• Gender-specific cutoffs for normal EF: ≥11 mm for women, ≥13 mm for men 3
• Severe LV dysfunction: <8 mm in adults, <6 mm indicates severely reduced EF 2, 3

Clinical Applications

Assessment of LV Longitudinal Function

MAPSE provides complementary information to ejection fraction by specifically measuring longitudinal myocardial function, which is often impaired earlier than global EF in various cardiac pathologies 1. The 2016 ASE/EACVI guidelines emphasize that abnormal LV longitudinal systolic function can be detected by MAPSE measurements using M-mode, particularly in patients with heart failure with preserved ejection fraction (HFpEF) where global longitudinal function is often impaired despite normal EF 1.

Advantages Over Other Parameters

MAPSE offers several practical advantages 4, 5, 6:

• Simplicity: Fast acquisition (approximately 51 seconds vs 192 seconds for Simpson's method) 7
• Feasibility: Works even with poor acoustic windows where strain imaging may fail 5
• Reproducibility: Can be measured by untrained observers with high accuracy 3
• No special software required: Unlike global longitudinal strain, which requires vendor-specific software 8

Correlation with Other Cardiac Parameters

Recent research demonstrates strong correlations 9, 6, 7:

• Global longitudinal strain: r = 0.53-0.535 (strong correlation) 9, 6
• LV ejection fraction: r = 0.64 (moderate correlation) 6, r = 0.324 9
• Predictive equation: LVEF = 3.27 × MAPSE (mm) + 18.79 7
• Cutoff for preserved EF: MAPSE of 10.325 mm predicts EF >50% with 90.7% sensitivity and 90.6% specificity 7

Clinical Scenarios Where MAPSE Is Particularly Valuable

Heart Failure with Preserved Ejection Fraction (HFpEF)

In patients with normal EF and inconclusive diastolic filling data, reduced MAPSE (along with reduced s' velocity and impaired global longitudinal strain) indicates myocardial dysfunction 1. This is consistent with the tight coupling between LV systolic and diastolic functions 1.

Early Detection of Systolic Dysfunction

MAPSE frequently detects reduced longitudinal function despite preserved LVEF across multiple pathologies 6. This makes it particularly useful as:

• Early marker in hypertensive heart disease where compensatory increased circumferential deformation may mask reduced longitudinal function 5
• Indicator of subendocardial fibrosis in aortic stenosis 5
• Marker of myocardial dysfunction in patients with normal EF but suspected cardiac disease 10

Prognostic Value

The 2025 ESICM guidelines on circulatory shock note that increased MAPSE was independently associated with lower 28-day mortality in septic shock 11. Additional research confirms strong prognostic value 12, 13, 6:

• Independent predictor of hospitalization (OR: 0.284) and in-hospital mortality (HR: 0.002) 12
• Superior prognostic performance compared to LVEF and global longitudinal strain in several studies 6
• Correlation with diastolic dysfunction: Inverse relationship with elevated LV filling pressures (E/e' >14) 9, 12

Point-of-Care and Critical Care Settings

The 2020 ESPNIC guidelines on POCUS recommend MAPSE as a semi-quantitative measure of LV systolic function in critically ill neonates and children 2. The 2025 ACR Appropriateness Criteria acknowledge MAPSE as a surrogate for global longitudinal strain when assessing LV longitudinal deformation 10.

Important Caveats and Limitations

Technical Considerations

• Angle dependency: Proper alignment in the apical 4-chamber view is essential
• Regional wall motion abnormalities: May affect accuracy in specific segments
• Atrial fibrillation: Beat-to-beat variability requires averaging multiple measurements
• Mitral valve disease: Primary mitral regurgitation or stenosis may affect measurements 1

When MAPSE May Be Less Reliable

• Mitral annular calcification: Can restrict annular motion independent of myocardial function
• Post-cardiac surgery: Altered cardiac geometry may affect measurements
• Severe mitral regurgitation: Regurgitant volume affects annular dynamics 1

Integration into Clinical Practice

The 2025 ACR guidelines and recent systematic reviews support MAPSE as having clinically important value meriting integration into routine cardiac imaging 10, 6. When LV ejection fraction is normal but clinical suspicion for heart failure exists, MAPSE analysis provides important information about diastolic dysfunction and related heart failure, and may predict prognosis 12.

The 2016 ASE/EACVI guidelines suggest that in patients with normal EF and inconclusive diastolic data, alternative indices like MAPSE or pulsed Doppler tissue imaging-derived mitral annular peak systolic velocity (s') should be used when regional tracking is suboptimal for strain imaging 8.

Practical Algorithm for Use

1. Measure MAPSE routinely in apical 4-chamber view using M-mode at lateral and/or septal mitral annulus
2. Apply age and gender-specific cutoffs to determine normal vs. abnormal values
3. If MAPSE is reduced (<12 mm lateral in adults) despite normal EF, consider:
   • Early systolic dysfunction
   • Subendocardial ischemia or fibrosis
   • Increased risk for adverse outcomes
4. Combine with diastolic parameters (E/e', LA volume index) for comprehensive assessment in HFpEF 1
5. Use for prognostic stratification in heart failure, post-MI, and critical illness 11, 12, 13, 6