The diagnostic and prognostic utility of mitral annular plane systolic excursion (MAPSE): A systematic review

The diagnostic and prognostic utility of mitral annular plane systolic excursion (MAPSE): A systematic review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search The diagnostic and prognostic utility of mitral annular plane systolic excursion (MAPSE): A systematic review Debbie Falconer , Fredrika Fröjdh , Nikolas Wyeth , Daniel Brieger , Gaby Captur , View ORCID Profile Rebecca Kozor , View ORCID Profile Martin Ugander doi: https://doi.org/10.1101/2025.03.05.25323051 Debbie Falconer 1 University College London , Gower Street, London, United Kingdom 2 Royal Free Hospital , Pond Street, London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Fredrika Fröjdh 3 Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet , Stockholm, Sweden Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nikolas Wyeth 4 Royal London Hospital , Whitechapel Road, London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Daniel Brieger 5 Kolling Institute , Royal North Shore Hospital, Sydney, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gaby Captur 1 University College London , Gower Street, London, United Kingdom 2 Royal Free Hospital , Pond Street, London, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Rebecca Kozor 5 Kolling Institute , Royal North Shore Hospital, Sydney, Australia 6 University of Sydney , Sydney, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Rebecca Kozor Martin Ugander 3 Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet , Stockholm, Sweden 5 Kolling Institute , Royal North Shore Hospital, Sydney, Australia 6 University of Sydney , Sydney, Australia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Martin Ugander For correspondence: martin.ugander{at}gmail.com Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Movement of the mitral annulus towards the left ventricular (LV) apex during systole, termed atrioventricular plane displacement (AVPD) or mitral annular plane systolic excursion (MAPSE), was first observed by Leonardo da Vinci in the 15 th century. MAPSE, a measure of longitudinal movement, shows good agreement between transthoracic echocardiography and cardiac magnetic resonance imaging (CMR), and can also be measured by transesophageal echocardiography and gated cardiac computed tomography. Manual measurement is fast, simple, and less reliant on good echocardiographic image quality than left ventricular ejection fraction (LVEF) or global longitudinal strain (GLS). Also, measurement can be easily automated, reducing reporting time. However, no major imaging guidelines advise routine measurement. We present a systematic review of studies appraising the diagnostic and prognostic performance of MAPSE from PubMed, Medline, Google Scholar and Embase until September 2025 in accordance with the PRISMA statement. Our findings demonstrate that MAPSE correlates with both LVEF ( r =0.64 [95% confidence interval 0.54– 0.74]) and GLS ( r =0.53 [0.45–0.63]), thus showing a modest association with measures of systolic function that may be particularly useful in patients with poor echocardiographic windows. Importantly, MAPSE falls while LVEF remains preserved across a range of pathologies, enabling earlier detection of systolic impairment than when using LVEF. MAPSE is also a powerful prognostic tool, outperforming both LVEF and GLS in predicting adverse events in several studies. Taken together, MAPSE has a clinically useful and important role that merits integration into routine cardiac imaging and care. Introduction First described by Leonardo Da Vinci in the 15 th Century ( 1 ), mitral annular plane systolic excursion (MAPSE) refers to the movement of the mitral annulus towards the apex during systole arising from ventricular contraction ( 2 ). MAPSE has also been referred to as movement of the mitral ring or atrioventricular plane displacement (AVPD). The term MAPSE came into common use in the early 2000s, and for simplicity, shall be used throughout this review. In the majority of patients, the cardiac apex is effectively fixed relative to the chest wall meaning long-axis contraction of the heart can be measured through the change in position of the mitral annulus. MAPSE, therefore, is a marker of longitudinal left ventricular (LV) movement, which contributes 60% of the total stroke volume ( 3 ). This proportion is constant across healthy hearts, elite athletes, and patients with dilated ( 4 ) and ischaemic cardiomyopathy, even when the absolute longitudinal function is decreased ( 5 ). Despite a growing body of literature pointing to the usefulness of MAPSE as a measure of cardiac function, the majority of contemporary imaging protocols do not advise routine measurement, including the most recent guidelines from the British Society for Echocardiography ( 6 ) (BSE), American Society of Echocardiography (ASE) ( 7 ), European Association of Cardiovascular Imaging (EACVI) ( 8 ), and the Society for Cardiovascular Magnetic Resonance (SCMR) ( 9 ). Although the BSE recommends a single MAPSE measurement as part of a comprehensive dataset ( 6 ), it is not routinely performed in most institutions. EACVI suggests MAPSE can be measured if other markers of longitudinal function are not available ( 8 ). Left ventricular ejection fraction (LVEF) is the mainstay for assessing systolic function, and normal LVEF can be maintained until late stages of a disease by a compensatory increase in radial function ( 10 , 11 ), meaning early systolic impairment is missed when assessed by LVEF alone. Global longitudinal strain (GLS) is a myocardial deformation analysis reflecting primarily longitudinal contraction, and it detects changes in systolic function before LVEF is impaired ( 12 ). Strain can be expressed as a function of the entire LV, termed long-axis strain, or on a regional basis, the latter of which has been widely adopted in cardio-oncology. Both GLS and LVEF are highly dependent on image quality. Conversely, MAPSE requires only measurement of mitral annular movement, so is less limited by imaging quality or user experience ( 13 ). MAPSE can be measured using transthoracic echocardiography (TTE) ( Figure 1 ), cardiac magnetic resonance (CMR) ( Figure 2 ), cardiac computer tomography (CT), and transesophageal echocardiography, and shows good agreement between modalities ( 14 ). MAPSE can also be easily automated, reducing reporting time ( 15 ). Therefore, excluding MAPSE from routine imaging may result in the loss of an easily attainable but informative imaging biomarker. Download figure Open in new tab Figure 1. Examples of MAPSE measurement using M-mode echocardiograph in a person with (A) normal systolic function and (b) impaired systolic function. Reproduced with permission from Hu et al 13 , 2012. Abbreviation: MAPSE, mitral annular plane systolic excursion Download figure Open in new tab Figure 2. Example of MAPSE measurement using CMR. MAPSE measurement using CMR on 4-chamber cine view from lateral and septal annulus. Adapted with permission from Mayr et al 89 , 2020. Abbreviations as per Figure 1 . This study aimed to systematically review evidence outlining the diagnostic and prognostic utility of MAPSE in adult cardiology patients, where possible comparing its performance to LVEF and GLS. The review addresses the following clinical questions: What are the normal values for MAPSE? When LVEF and GLS are not available, can MAPSE be used to diagnose systolic dysfunction (i.e. how closely does MAPSE correlate to these measurements)? For what pathologies can MAPSE be used to detect early systolic dysfunction in the presence of a normal LVEF? In cardiovascular disease, how strongly is MAPSE associated with prognosis, and how does this compare with LVEF and GLS? Methods This systematic review is presented in accordance with the PRISMA statement ( 16 ). PubMed, Medline, Embase and Google Scholar were searched (terms in supplementary material ). Retrospective and prospective observational studies assessing the diagnostic and prognostic utility of MAPSE in adult humans until September 2025 were included. Studies of healthy cohorts and those with pathology were included, and were grouped into the following categories: Studies defining normal values Diagnostic studies: Measuring association between MAPSE with other markers of systolic function. Comparing MAPSE in populations with a known pathology vs healthy controls where LVEF is normal. Prognostic studies measuring the association between MAPSE and outcomes in cardiovascular disease and comparison with LVEF and GLS where available. Non-English publications, abstracts and studies pertaining to congenital heart disease were excluded ( Supplementary Table S-1 ). Review articles were not included, but references were manually searched for additional publications. Titles and abstracts were independently screened by both reviewers (DF and FF). If abstracts were insufficient to determine whether the publication should be included or not, the full text was read to inform the final decision and in cases of uncertainty a third reviewer (MU) was consulted. Data from each study was extracted and tabulated by one reviewer (DF) and confirmed by another reviewer (FF). Collected data included study author and year, number of participants, pathology, imaging modality, measurement point, and outcomes. Outcomes included correlations and MAPSE values per group for diagnostic studies, and hazard ratios or odds ratios for prognostic studies as reported. Meta-analysis of correlation coefficients ( r ) was calculated as a mean correlation [95% confidence interval] weighted by sample size to analyse overall correlation between MAPSE and LVEF or GLS using the Hunter-Schmidt method ( 17 ) in R (PsychMeta package, R version 4.2.3, 2023). Meta-correlation was calculated for each measurement site (e.g. lateral MAPSE) when reported by at least two studies. High agreement has previously been reported between CMR and TTE measurements ( 14 ), and between manual and automated approaches ( 15 ), therefore these modalities were considered sufficiently comparable to be analysed together. For studies assessing MAPSE as a diagnostic marker when LVEF is normal and as a prognostic marker, there was substantial heterogeneity in measurement location, disease populations, and diagnostic/ prognostic criteria. Therefore, a formal meta-analysis was deemed inappropriate and the results are described narratively. Quality Assessment The methodological quality of included cohort and cross-sectional studies was assessed using the Newcastle-Ottawa Scale (NOS) ( 18 ) by two reviewers (DF and NW), and a third (MU) was consulted in cases of disagreement. Standard NOS criteria ( Supplementary Table S-2 ) was applied to cohort studies reporting diagnostic and prognostic outcomes. For cross-sectional studies reporting MAPSE at a single timepoint in groups with preserved LVEF, a modified version of the NOS adapted for cross-sectional studies was used as previously described ( 19 , 20 ) ( Supplementary Table S-3 ). The modified NOS evaluates participant selection, comparability of groups and the assessment of outcomes with a maximum score of 10 (compared with 9 for the standard NOS). Studies were then classified as high (7–9/ 10), moderate ( 5 – 6 ), or low (<5) quality. As there are no established quality assessment tools specifically designed for studies evaluating correlation between measurements, a formal risk of bias assessment was not conducted for this group of studies. Results The search was performed December 2024–September 2025, and 92 studies were included ( Figure 3 ) . Summaries of included studies are presented in Tables 1 – 4 . View this table: View inline View popup Download powerpoint Table 1. Summary of studies presenting reference values in healthy subjects Download figure Open in new tab Figure 3. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart outlining study selection. Abbreviations as per Figure 1 . Normal MAPSE values Five studies (n= 3576) ( Table 1 ) report MAPSE values in healthy cohorts. All studies observed an inverse relationship with age ( 21 - 25 ). MAPSE as a method of diagnosing systolic impairment 1. Correlation between MAPSE and other markers of systolic function Limited echocardiographic windows can render accurate assessment of systolic function challenging. The relationship between MASPE and other markers of systolic function has been investigated to ascertain if MAPSE can be used when LVEF or GLS are not available. Correlation between MAPSE and LVEF In a meta-analysis of 21 studies, LVEF and MAPSE demonstrated a moderate pooled correlation across all measurement sites (n = 2864; r = 0.64 ± 0.21 [95% CI: 0.54–0.74]) ( 21 , 26 – 45 ); Table 2 ; Figure 4 ). More specifically, LVEF correlated with MAPSE measured at the lateral apical four-chamber view (n = 2011; r = 0.49 [0.27–0.70]), the mean of lateral and septal sites (n = 968; r = 0.70 [0.45–0.95]), and the mean of lateral, septal, anterior, and inferior sites (n = 366; r = 0.79 [0.56–1.00]). View this table: View inline View popup Table 2. Summary of studies comparing MAPSE with other measures of systolic function. Download figure Open in new tab Figure 4. Summary of individual studies and meta-correlation between MAPSE and LVEF. The size of the individual circles denotes the population size. The red diamond denotes the meta-correlation and 95% confidence interval. Studies are colour coded as per measurement site for MAPSE: blue= lateral point on apical 4 chamber view; black= mean of lateral and septal points on apical 4 chamber view; pink= mean of lateral, septal, anterior and inferior points from apical 4 and 2 chamber views; purple= other. Abbreviations: LVEF, ejection fraction, other as per Figure 1 . Correlation between MAPSE and tissue Doppler imaging (TDI) There was a correlation between MAPSE and tissue Doppler imaging (TDI) in 92 patients ( r =0.9, p<0.001) ( 46 ) and 56 healthy subjects ( r =0.56, p <0.0001) ( 47 ). Due to the limited number of studies, no meta-correlation performed was performed for this association. Correlation between MAPSE and GLS A meta-correlation of 15 studies ( n =5078) showed a moderate pooled correlation between MAPSE and GLS (r=0.53±0.17 [0.45–0.63]) (15,22,33, 38, 48-58) ( Table 2 ; Figure 5 ). Specifically, studies using lateral MAPSE alone reported a correlation of 0.45 [0.33–0.73] (n = 231), while studies using the mean of lateral and septal MAPSE reported a stronger correlation of 0.79 [0.56–1.00] (n=366). When MAPSE was measured at six points across three apical views, the correlation was 0.66 [0.46–0.87] (n=1992). Download figure Open in new tab Figure 5. Summary of individual studies and meta-correlation between MAPSE and the absolute value of GLS. The size individual circles denotes the population size. The red diamond denotes the meta-correlation and 95% confidence interval. Studies are colour coded as per measurement site for MAPSE: blue= lateral point on apical 4 chamber view; black= mean of lateral and septal point on apical 4 chamber view; pink= mean of lateral, septal, anterior, inferior, anteroseptal and inferolateral points from apical 4, 2 and 3chamber views; purple= other. Abbreviations: GLS, global longitudinal strain; others as per Figure 1 . Correlation between MAPSE and tissue Doppler imaging (TDI) There was a correlation between MAPSE and tissue Doppler imaging (TDI) in 92 patients ( r =0.9, p<0.001) ( 46 ) and 56 healthy subjects ( r =0.56, p <0.0001) ( 47 ). Due to the limited number of studies, no meta-correlation performed was performed for this association. Correlation between MAPSE and GLS A meta-correlation of 15 studies ( n =5078) showed a moderate pooled correlation between MAPSE and GLS (r=0.53±0.17 [0.45–0.63]) (15,22,33, 38, 48-58) ( Table 2 ; Figure 5 ). Specifically, studies using lateral MAPSE alone reported a correlation of 0.45 [0.33–0.73] (n = 231), while studies using the mean of lateral and septal MAPSE reported a stronger correlation of 0.79 [0.56–1.00] (n=366). When MAPSE was measured at six points across three apical views, the correlation was 0.66 [0.46–0.87] (n=1992). 2. MAPSE as a marker of reduced longitudinal systolic function when LVEF is normal Thirty-one studies compared MAPSE in patients and controls where LVEF was normal ( Table 3 ) (14, 53, 59-79, 81-88). These studies were undertaken in the following patient groups. View this table: View inline View popup Table 3. Summary of studies using MAPSE to diagnose left ventricular systolic impairment when LVEF is normal Hypertension (HTN) or type 2 diabetes mellitus (T2DM) Six TTE studies of subjects with HTN and/or T2DM demonstrated MAPSE was reduced compared with age and sex-matched controls ( 59 - 64 ). In one study, MAPSE was similar in cohorts with diabetes or HTN (13.5±2.3mm and 13.2±2.2mm, respectively) but lower in those with both conditions (11.5±3.0mm, p <0.05), suggesting a cumulative effect ( 61 ). A study of 45 patients undergoing sleeve gastrectomy showed an increase in MAPSE 6 months post-surgery (median 16mm vs 18m, p<0.01) which may be related to the associated reduction in HTN and DM, though several other cardiovascular risk factors were also reduced ( 65 ). Aortic stenosis (AS) Mean MAPSE was lower in a cohort of 49 patients with AS (all grades) compared with 133 controls (9.2±2.3mm vs 10.7±2.8mm, p <0.001) ( 66 ). A prospective study ( n =78) found lateral MAPSE was lower in patients with severe AS compared with controls ( p <0.002) whilst septal MAPSE was lower in mild, moderate and severe AS ( p <0.001) ( 67 ). In 58 patients undergoing surgical replacement for severe AS, MAPSE was higher in patients with no myocardial fibrosis (10.7±1.2mm) compared with mild (8.8±1.4mm, p <0.05) or severe (4.9±1mm, p <0.001) changes on biopsy at the time of surgery. Patients with no or mild fibrosis were more likely to experience an improvement in symptoms to New York Heart Association (NYHA) grade I or II, whilst patients with severe fibrosis remained in NYHA class III or IV nine months post-surgery. LVEF did not predict improvement in symptoms ( 68 ). Likewise, a study of 101 patients undergoing transcatheter aortic valve implantation reported an increase in MAPSE, but not LVEF, post-procedure (9.1±3.2 to 10.2±3.3mm, p =0.006) ( 69 ). A study of 205 patients with severe AS showed a reduction in MAPSE of >2mm per serial scan had an increased likelihood of requiring intervention (HR 1.95 [1.04– 3.66] p=0.04) when LVEF remained preserved ( 70 ). MAPSE was also lower in low-flow low-gradient severe AS compared with moderate (12.8±1.7mm vs 5.0mm±0.9mm, p <0.05) ( 71 ) and pseudosevere AS (9.8±2.6 vs 11.6±2.2mm, p<0.05) ( 72 ), and may assist in differentiating these groups where there is uncertainty. HfpEF Five studies found MAPSE is lower in patients with diastolic dysfunction (DD) than controls ( 53 , 73 - 6 ). Rather than acting as a marker of pure DD, reduced MAPSE likely reflects concurrent longitudinal systolic dysfunction, as systolic and diastolic function are inextricably linked ( 13 ), and may result from a higher prevalence of comorbidities associated with DD such as HTN and DM. In patients with HFpEF undergoing cardiopulmonary exercise testing, MAPSE was lower at rest (10.9±2.1mm vs 12.1±2.2mm, p =0.008), and augmented less during exercise in patients with DD compared with controls (12±2.2mm vs 16.2±2.7mm, p <0.001) ( 53 ). MAPSE was also lower in three cohorts with LV hypertrophy (LVH) ( 77 - 9 ). In disease states where the LV hypertrophies or dilates, less longitudinal contraction is required to generate the same stroke volume, so a reduction in MAPSE reflects both increased LV mass and size ( 80 ).. HCM Two CMR-based studies ( 14 , 81 ) found MAPSE was lower in patients with HCM vs controls. Septal MAPSE was reduced compared with lateral MAPSE in patients with outflow obstruction (9.2±3.7mm vs 11±3.6mm, p =0.04) reflecting greater impairment in the septum, which is the area of greatest disease ( 14 ). Mitral regurgitation CT-derived MAPSE was lower in patients with severe primary mitral regurgitation (9.9±1.4mm) compared with healthy controls (11.9±1.0mm) and LVEF was preserved relative to their valve function (64±5.5% and 54±6.9% respectively). Furthermore, MAPSE fell as mitral annular calcification increased in severity (8.8±1.0mm vs 5.3±0.7mm for grade 1 and 4 respectively ( 82 ). Marfan’s syndrome MAPSE was lower in all 5 measurement positions in a TTE study compared with controls. Of note, LVEF was also lower in the Marfan’s group, but was well within normal range (66 vs 71%, p <0.001) ( 83 ). Anthracycline-related cardiac disease (ARCD) Post-chemotherapy MAPSE was lower in those who did not recover systolic function compared with those with good recovery (11.7±1.5 vs 15.7±3.1mm, p =0.03) ( 84 ) from ARCD, suggesting MAPSE may identify those most at risk from ongoing impaired function when ARCD occurs. Of note, two studies demonstrated no difference in pre-chemotherapy MAPSE in patients who developed ARCD compared with those who did not ( 85 , 86 ). Hypothyroidism A study of 81 patients with hypothyroidism found lateral MAPSE was lower than controls with similar rates of typical cardiovascular risk factors and normal LVEF (17±2 vs 15±3mm, p=0.002), though both groups fell within normal range. ( 87 ). Mixed connective tissue disease (MCTD) MAPSE was lower in 77 patients with MCTD and normal LVEF and GLS compared with controls ( 88 ) (13.7±2.1 vs 15.3±2.3, p<0.001). MAPSE as a prognostic biomarker The prognostic capability of MAPSE has been investigated in 29 studies across a range of pathologies ( Table 4 ) (15, 37, 43, 51, 52, 89–112). View this table: View inline View popup Table 4. Studies comparing MAPSE with LVEF or GLS as a prognostic marker General outpatient cohorts In the largest cohort, which included individuals with pathology and normal scans undergoing outpatient CMR ( n =1572), automatically-measured MAPSE was a better predictor of death or hospitalisation for heart failure (HR 1.7 [1.5–2.0] per mm decrease, p <0.001) compared with GLS (HR 1.5 [1.3–1.7] per % increase, p <0.001) or LVEF (HR 1.4 [1.2–1.6] per % decrease, p <0.001) on multivariable analysis ( 15 ). A similarly heterogeneous cohort of 400 patients followed up for 14 months, found lateral MAPSE was the strongest imaging-based predictor of MACE after multivariable analysis (HR 1.34 per 2mm decrease, p =0.02) whereas neither LVEF nor the presence of LGE remained associated ( 89 ). In a TTE-based study of 512 patients, lateral MAPSE was the only imaging-based predictor of mortality (HR 0.01 [0.00–0.52] for MAPSE ≥12 vs <12 mm, p =0.02) ( 43 ), as early as 30 days after imaging ( p <0.001). HfrEF Multiple CMR and TTE studies have demonstrated the prognostic significance of MAPSE ( 90 - 94 ). The largest, a multicentre study of 1040 patients with HFrEF undergoing CMR showed lateral MAPSE was the strongest imaging-based biomarker in predicting mortality (HR 2.1 [1.5– 2.8] per mm decrease, p 9mm had a similar survival regardless of LVEF ( p =0.96) ( 90 ). When compared, MAPSE outperformed LVEF ( 90 , 93 ) and GLS ( 94 ) in predicting prognosis. IHD CMR-measured MAPSE was a better predictor of major adverse cardiac events (MACE) (death, MI, stroke, heart failure) than LVEF in an ST-elevation myocardial infarction (STEMI) cohort followed up for 3 years (area under curve 0.74 vs 0.61, p <0.01) ( 95 ). MAPSE <9mm remained a predictor of MACE in models of clinical and imaging risk factors (HR 6.0 [2.5– 14.7], p <0.01) where LVEF was not associated. Another study of 165 patients post-acute coronary syndrome (ACS) also found MAPSE was a stronger predictor of MACE than LVEF (HR 0.83 [0.73–0.94] per mm increase, p =0.004 vs HR 0.96 [0.94– 0.99] per % decrease, p =0.01) ( 96 ). In 271 patients with suspected ACS, those with MAPSE <8mm had a risk ratio of 3.0 ( p <0.001) for death or heart failure hospitalisation during follow-up compared with the remainder of the cohort ( 97 ). In a different cohort with suspected ACS (n=233) lateral MAPSE on CMR predicted MACE during follow up (HR 1.4 [1.1– 1.8]) ( 95 ), whereas LVEF did not. Conversely, another CMR study of 445 patients 2-4 days post-revascularisation for STEMI found MAPSE was a predictor in univariable analysis (HR 0.80 [0.72–0.89] per mm increase), but not when adjusted for other imaging biomarkers ( 99 ). This difference may arise from the model’s use of CMR-biomarkers such as infarct size or microvascular obstruction that were not adjusted for in other studies. In 333 patients with stable IHD, MAPSE was the only imaging marker that correlated independently with mortality (OR 1.6 [1.4–2.0] per mm decrease, p <0.001) ( 100 ). Takotsubo cardiomyopathy Among patients (n=53) with MAPSE <10mm on admission, mortality was higher after 12 months follow-up, but there was no difference within the first year. MAPSE <10mm was a predictor of mortality (HR 5.1 [1.3–19.2], p <0.01), whilst LVEF <35% was not ( 101 ). Hypertension 5.1 years following a CMR (n=1735) lateral MAPSE was associated with increased mortality (HR 1.4 [1.3–1.5] per mm decrease, p <0.001) in the whole cohort, as well as in the subgroup analysis of patients with preserved LVEF (HR 1.3 [1.2–1.5] per mm decrease, p <0.001) ( 102 ). GLS was a predictor of MACE in multivariable analysis, but weaker than MAPSE (HR 1.18 [1.14–1.22]per % increase, p <0.001) and LVEF was not a predictor at all. A TTE study (n=156) also reported mean MAPSE was a predictor of MACE in multivariable analysis (HR 0.81 [0.67– 0.98 per standard deviation reduction, p <0.05) ( 103 ). HCM MAPSE was lower in those with MACE (death, transplant or ventricular arrhythmia) (6.9±1.9mm vs 10.2±3.1mm, p =0.01) with no difference in LVEF between groups ( p =0.86) ( 14 ). Amyloidosis In 191 patients with wildtype transthyretin amyloidosis, MAPSE was the only imaging-based predictor of mortality in multivariable analysis (HR 0.19 [0.04–0.83], p =0.003) ( 104 ). A CMR-based study of 68 AL amyloid patients showed lateral MAPSE was a stronger predictor of death or heart transplant (HR 0.23 [0.10–0.56] per mm decrease, p =0.001) than LVEF or GLS ( 105 ). However, two other TTE studies of patients with AL amyloid found MAPSE predicted death in uni-, but not multivariable analysis ( 106 , 107 ). MAPSE was a stronger predictor than LVEF in both cohorts, but did not out-perform GLS. Heart transplant MAPSE measured by STE at the midpoint of the mitral annulus in 155 patients was a stronger predictor of death/hospitalisation than GLS (HR 0.68 [0.56– 0.83] vs 0.76 [0.66–0.87], p <0.001) or LVEF (not associated) ( 52 ). Moreover, MAPSE was obtainable in a greater proportion (86%) compared to LVEF or GLS (72%) ( 52 ). Pulmonary arterial hypertension (PAH) In 71 patients with PAH, MAPSE by CMR was higher in survivors (12.3±3.0mm vs 10.0±3.0mm, p =0.02). MAPSE predicted death or transplantation (HR 1.2 [1.0– 1.3] per mm decrease p =0.01) whilst LVEF and right ventricular EF were not associated ( 108 ). Septic shock Two studies found MAPSE to be the sole or strongest imaging biomarker for predicting mortality in multivariable analysis ( 37 , 109 ). LVEF was not a predictor of mortality in any study. Atrial fibrillation (AF) A study of 160 patients with AF showed MAPSE was a predictor of mortality (OR 1.4 [1.1–1.7] per mm decrease, p<0.01) where LVEF was not. ( 110 ). Acute pulmonary embolism (PE) MAPSE <11mm predicted mortality or the need for advanced therapies in 363 patients with acute PE and preserved LVEF (OR 3.5 [1.4–9.0], p =0.01). MAPSE <11mm combined with tricuspid annular plane systolic excursion (TAPSE) <16mm was strongly associated with adverse outcomes (OR 10.8 [3.1–37.8], p <0.01). LVEF <50% was also an adverse prognostic marker (OR 4.1 [1.4–12.0], p =0.011) ( 111 ). Coronavirus disease-2019 (COVID-19) MAPSE was the only left-heart imaging biomarker that differed in patients who died and those who survived (11±3 vs 12±3mm, p =0.006) ( 112 ). In multivariable analysis, MAPSE (HR 1.6 [1.2– 2.2] per mm decrease, p =0.006) and right atrial volume index (RAVI) were predictors of mortality. Difference in RAVI is likely to represent the higher ventilatory requirements of the more unwell patients. Quality of evidence assessment Overall, the studies demonstrated high methodological quality. NOS and modified-NOS scores ranged from 6–9, and all-but-one study was rated as high quality (7 or higher). No studies were rated as low-quality. A full breakdown of individual study scores is provided in Supplementary Tables S-4–6 . Discussion This systematic review found a moderate-to-strong correlation between MAPSE and LVEF, and a moderate correlation between MAPSE and GLS. In cohorts with a normal LVEF, MAPSE was lower in patients with HTN, T2DM, AS, HCM, Marfan’s syndrome, hypothyroidism and mixed connective tissue disease compared with matched healthy controls. Measuring MAPSE routinely, and monitoring its change over time in these conditions, may allow detection of early systolic impairment that would otherwise be missed. In the largest study of general outpatients, MAPSE was the strongest predictor of death or hospitalisation, outperforming LVEF and GLS ( 15 ). MAPSE predicted mortality or MACE in cohorts with HFrEF, IHD, Takotsubo cardiomyopathy, HTN, amyloidosis, post-heart transplant, pulmonary hypertension, AF and COVID-19, where LVEF was either a weaker predictor or not associated. MAPSE was also a stronger predictor than GLS in cohorts with hypertension and amyloidosis. Taken together, routine incorporation of MAPSE into clinical studies with any of the above conditions would seem appropriate to identify the most at-risk patients. A specific clinical context in which MAPSE may provide additional value for guiding treatment is aortic stenosis. In this setting, MAPSE — but not LVEF — has been shown to improve following intervention ( 69 ) and is associated with postoperative symptomatic improvement ( 68 ). Yet, current guidelines recommend reduced LVEF as an indication for intervention in asymptomatic patients ( 113 ). Importantly, long-axis movement can also be assessed using gated cardiac computed tomography ( 82 ), which is routinely performed as part of the pre-intervention workup. Measurement considerations In this study, the strongest correlation with LVEF was observed using the mean MAPSE derived from lateral, septal, anterior, and inferior sites. The strongest correlation with GLS was found using the mean of lateral and septal MAPSE. Although incorporating additional measurement sites may require more operator-time, our data suggests it may provide greater diagnostic value and a more comprehensive assessment of systolic function. Automated measurements have proven possible using both TTE and CMR, and show good agreement with manual measurements ( 114 ). This may be of value particularly in patients with atrial fibrillation, where MAPSE is likely to vary from beat to beat and may require an average of multiple measurements to be taken. MAPSE can also be measured by speckle tracking echocardiography, which automatically tracks and measures annular movement with less angle dependence, but is only available with specific vendor software. Limitations of MAPSE The main limitation with MAPSE is the lack of regional assessment of LV function ( 115 ), for which visual assessment and strain remain essential. As the use of M-mode on TTE is angle dependent, off-axis views may underestimate MAPSE, reducing specificity. However, MAPSE can readily be measured in a less angle-dependent fashion using a simple linear caliper applied to a 2D image. MAPSE is also reduced in patients having undergone mitral valve replacement ( 116 ), when it may reflect post-surgical changes moreso than inherent LV myocardial function. Finally, as mentioned, widespread application of MAPSE is currently limited by a lack of standardised practice. However, the generation of normal values from large datasets may lead to the inclusion of MAPSE in guidelines, and with it set the standards for acquisition, measurement, and interpretation. Limitations of this study Study quality was assessed using the NOS, which, while widely used, is subjective and may not fully capture all sources of bias in observational studies. As aforementioned, there was significant methodological heterogeneity between studies, particularly in the measurement sites and, as well as study populations and outcome definitions. These variations limited the ability to perform a formal quantitative meta-analysis and precluded direct pooling of results. As a result, it is not possible to derive firm numerical thresholds to guide clinical practice currently. Instead, our findings underscore the promising clinical potential of MAPSE. Conclusions MAPSE is a marker of global longitudinal LV function and has a strong association with clinical prognosis. Measurement of MAPSE allows assessment of LV systolic function even with compromised echocardiographic image quality. Early systolic impairment that may be missed when using LVEF alone can be detected using MAPSE. MAPSE also aids in prognostication across multiple cardiac conditions including hypertension, aortic stenosis, and ischaemic heart disease, outperforming LVEF and GLS in several pathologies. Despite the advancement of more sophisticated techniques within cardiac imaging, new studies continue to highlight the clinical information that MAPSE has to offer clinicians and patients. Those contemplating using MAPSE in their clinical practice may consider both the wealth of data supporting its use presented herein, and da Vinci’s timeless sage words that “simplicity is the ultimate sophistication” ( 117 ). Data Availability All data produced in the present work are contained in the manuscript Central graphical abstract Clinical utility of MAPSE Download figure Open in new tab Central graphic created by authors (DF), individual panels reproduced and labelled with permission from Mayr 89 (CMR), Yu 117 (TOE) and Lorenzatti 118 (CT). Footnotes Conflicts of interest: none Funding: This work is supported in part by the British Cardiology Society/ Heart Research UK clinical fellowship. DF is also supported by the UCL-Wellington fellowship. The revision has been made in response to new papers being published on the topic. 3 new studies have been added to the text and tables, resulting in small changes to figures 3, 4 and 5. Abbreviations and acronyms ACS acute coronary syndrome AVPD atrioventricular plane displacement AS aortic stenosis AF atrial fibrillation AI artificial intelligence ARCD anthracycline related cardiac dysfunction BSE British Society of Echocardiography CABG coronary artery bypass graft CI confidence interval CMR cardiovascular magnetic resonance COVID-19 coronavirus disease 2019 CT computed tomography DD diastolic dysfunction DMD Duchenne Muscular Dystrophy EACVI European Association of Cardiovascular Imaging ED emergency department GLS global longitudinal strain HCM hypertrophic cardiomyopathy HFpEF heart failure with preserved ejection fraction HFrEF heart failure with reduced ejection fraction HTN hypertension HR hazard ratio IHD ischemic heart disease LAS left atrial strain LFLG low-flow low-gradient LGE late gadolinium enhancement LOA limits of agreement LV left ventricle LVEF left ventricular ejection fraction LVH left ventricular hypertrophy MACE major adverse cardiovascular event MAPSE mitral annular plane systolic excursion NYHA New York Heart Association OR odds ratio PAH pulmonary artery hypertension PE pulmonary embolism POCUS point-of-care ultrasound TAVI Transaortic catheter valve implantation TDI tissue Doppler imaging TMAD tissue mitral annular displacement TTE transthoracic echocardiography TEE transesophageal echocardiography RAVI right atrial volume index RV right ventricle SCMR Society for Cardiovascular Magnetic Resonance STE speckle tracking echocardiography. 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Share The diagnostic and prognostic utility of mitral annular plane systolic excursion (MAPSE): A systematic review Debbie Falconer , Fredrika Fröjdh , Nikolas Wyeth , Daniel Brieger , Gaby Captur , Rebecca Kozor , Martin Ugander medRxiv 2025.03.05.25323051; doi: https://doi.org/10.1101/2025.03.05.25323051 Share This Article: Copy Citation Tools The diagnostic and prognostic utility of mitral annular plane systolic excursion (MAPSE): A systematic review Debbie Falconer , Fredrika Fröjdh , Nikolas Wyeth , Daniel Brieger , Gaby Captur , Rebecca Kozor , Martin Ugander medRxiv 2025.03.05.25323051; doi: https://doi.org/10.1101/2025.03.05.25323051 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Cardiovascular Medicine Subject Areas All Articles Addiction Medicine (569) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4442) Dentistry and Oral Medicine (444) Dermatology (383) Emergency Medicine (609) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1511) Epidemiology (15230) Forensic Medicine (30) Gastroenterology (1126) Genetic and Genomic Medicine (6610) Geriatric Medicine (668) Health Economics (998) Health Informatics (4542) Health Policy (1370) Health Systems and Quality Improvement (1613) Hematology (543) HIV/AIDS (1266) Infectious Diseases (except HIV/AIDS) (15923) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (147) Nephrology (668) Neurology (6607) Nursing (346) Nutrition (999) Obstetrics and Gynecology (1146) Occupational and Environmental Health (957) Oncology (3337) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (664) Pediatrics (1693) Pharmacology and Therapeutics (692) Primary Care Research (712) Psychiatry and Clinical Psychology (5448) Public and Global Health (9238) Radiology and Imaging (2202) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (596) Sexual and Reproductive Health (714) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a01be0fa9daf4193',t:'MTc3OTc4OTA2MA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();