Manuskrip Magister - Edited
Manuskrip Magister - Edited
1
Department of Cardiology and Vascular Medicine, University of Sumatera Utara, Adam
Malik Hospital, Medan, Indonesia
* Email: [email protected]
Abstract
Background: Assessment of left ventricular diastolic function is an important part of the
routine echocardiographic examination to identify the underlying heart disease and determine
the appropriate treatment. Mitral annular displacement toward the apex in systolic plays
important role in pump function of the left ventricle. At the start of diastolic, the
atrioventricular (AV) plane begins to ascend rapidly toward the atrium away from the apex.
Atrial systole also contributes to ventricular filling by further displacing the AV plane in the
same direction, and this notice as the last part of the diastolic phase of AV plane
displacement and is associated with the P wave of an electrocardiogram.
Methode: A diagnostic test was performed to outpatients and inpatients undergoing elective
echocardiography at Department of Cardiology in Haji Adam Malik Hospital Medan from
October 2017 to February 2018 in accordance with inclusion and exclusion criteria. Mitral
annulus plane systolic excursion (MAPSE) examination was performed using M-mode
method on septal, lateral, inferior and lateral mitral annulus and then calculated mean. The
diastolic function is measured by assessing E/e. The value of the tested points was tested
using ROC curve statistic test and obtained sensitivity and specificity values. Further
assessed the strength of the relationship with bivariate analysis.
Result: A total of 81 samples were found in this study, with 41 samples meeting inclusion
and exclusion criteria. Mean MAPSE with cutoff value <13,625 had a sensitivity value of
62.5%, specificity 51.2%, positive predictive value of 58.3%, and a negative predictive value
of 55.5% (p <0.05). The result of bivariate analysis with Pearson method showed the
coefficient value of 0.242 (p <0.05).
Conclusion: MAPSE measurements had a weak positive correlation in determining left
ventricular diastolic function so it may help to determine the left ventricular diastolic function
along with available parameters.
Keywords: Mitral annular plane systolic excursion, MAPSE, mitral annular displacement,
diastolic function, echocardiography, E/e’.
INTRODUCTION
functions in the last two decades. Evaluation of diastolic function through doppler provides
especially remote areas, are the limitations of medical support equipment such as
echocardiography, whereas some regions have echocardiographic devices that are not
equipped with Doppler facilities which are the main modalities in determining diastolic
function. This study tested the modalities used to assess left ventricular diastolic function
valve plane to the apex at the time of systole indicates an important role in left ventricular
pump function. Atrioventricular displacement recording method is quite easy and the
magnitude of AV field displacement can be used to assess left the ventricular systolic
function in patients with acute myocardial infarction, coronary artery disease, and severe
chronic congestive heart failure. At the beginning of diastole, the AV field begins to rise
rapidly toward the atrium away from the apex. Atrial systole also contributes to ventricular
filling by moving the AV field further in the same direction, and this can be noted at the end
of the diastolic phase of AV field displacement and associated with the P wave on the EKG
(Alam, 2002).
METHODS
This was a cross-sectional study. The inclusion criteria were 35-70 years old, sinus
rhythm, had a left ventricular ejection fraction> 50%, had no significant mitral valve
deformities (mitral stenosis and / or mitral regurgitation), lacked significant aortic and aortic
root abnormalities (aortic stenosis, aortic regurgitation, or aortic dilatation), had no congenital
window.
(GE Medical systems) with a 3.5 MHz variable frequency transducer. Systolic function was
function using mitral inflow method (ratio E / e '), septal e', lateral e ', tricuspid regurgitation
rate (TR velocity), and left atrium volume (LA). Mitral annulus plane systolic excursion
(MAPSE) was measured on 4-chamber and 2-chamber pieces by placing the M-mode cursor
through 4 regions (septal, lateral, anterior, and inferior) of the mitral valve annulus and
measuring the distance between the lowest point at the beginning of systolic (the beginning of
the QRS complex) to the highest point at the end of systolic (end of wave T). After obtaining
all four values of MAPSE from all regions, an average MAPSE score was taken that reflects
the global longitudinal function in the left ventricle (Hu K et al., 2013).
Descriptive statistics were used to represent the entry of the study. The free variable
was the left ventricular diastolic function in the categorical scale, and the dependent variable
was the MAPSE in a numerical scale. The data were assessed for the normality of distribution
and transformed as appropriate. Results were expressed as frequencies and percentages for
categorical variables. Each characteristic of the data tested its significance between normal
and abnormal diastolic function. Cut-off points for numerical data are obtained through the
ROC curve, the area under the curve (AUC) was used to assess the accuracy of the diagnostic
test. Sensitivity, specificity, negative predictive value, and positive predictive value for each
dependent variable were obtained with 2x2 tables. While the MAPSE relationship with left
Total number of subjects was 81 people, consisting of 40 people with normal left
ventricular systolic and diastolic function (hereinafter referred to as controls) and 41 people
with normal left ventricular systolic function and abnormal left ventricular diastolic function
(hereinafter impaired diastolic function) . Male gender consisted of 21 people (51,2%) with
impaired diastolic function and control found 23 people (57,5%), while female gender
consisted of 20 people (28,8%) with impaired diastolic function and control found 17 people
(42,5%). The mean age of subjects with impaired diastolic function was 60.59 years while in
control was 48.83 years. Mean left ventricular ejection fraction in control subjects was
57.24% while in subjects with impaired diastolic function was 55.93%. The end diastolic
dimension of the left ventricle in control was 44.28 mm, while the subject with impaired
diastolic function was 43.41 mm. In addition TAPSE in control was 22.83 mm and in
subjects with impaired diastolic function was 21.22 mm. In MAPSE examination, the inferior
segment and mean MAPSE had significant p-value with control MAPSE value was 14.14
mm, while in subjects with impaired diastolic function was 13.34 mm.(Table 1)
The mean MAPSE echocardiographic data on diastolic function were searched for
cut-off value using ROC curve, then sought sensitivity, specificity, positive predictive value,
Mean MAPSE with a cutoff value of <13.625 mm (p <0.05) for abnormal left
To assess the correlation , this study use Pearson method because the samples were
distributed normaly. The coefficient of 0.242 was found which showed a weak positive
<0.05).(Table 3)
DISCUSSION
This study was a cross-sectional study that examined the MAPSE value in M-mode
research was conducted in Adam Malik hospital Medan since October 2017 until February
2018 and involving 81 sample. The sample were an outpatient and inpatient conducting
resulting in a larger residual volume in the left atrium in the final phase of the diastolic phase,
thus the higher the atrial preload. This results in a stronger left atrial contraction and elevated
left atrial activation, which is reflected in the increased contribution of left-handed AV plane
diastolic function is impaired only in hypertensive patients with normal ejection fraction and
fractional shortening which may indicate abnormal LV filling behavior. The diastolic
extension of the longitudinal fibers seems to contribute greatly to the diastolic behavior of the
with M-mode echocardiography from atrioventricular displacement plane have been shown to
be a simple method for assessing the systolic and diastolic function of the left ventricular
longitudinal fibers. In a variety of clinical settings, this index has been shown to carry
important diagnostic and prognostic information with impressive left ventricular dysfunction
from the moment. Indeed, some experts have proposed its use as a screening tool that
shortening initially thought to have a normal diastolic function or even isolated diastolic
dysfunction, have been shown to reduce the systolic function of the left ventricular
longitudinal fibers. This may indicate that the change in longitudinal shortening of the left
ventricle, determined by the function of the subendocardial fibers, is a very sensitive marker
of early systolic dysfunction. Longitudinal fiber diastolic function becomes abnormal only
function using M-mode echocardiography can identify left ventricular abnormal relaxation
The progress of echocardiography has gone hand in hand with the growing
knowledge of the function and role of atria in cardiovascular disease (Cameli et al., 2009,
Zile et al., 2002). Techniques for assessing diastolic function are still developing, looking for
a perfect noninvasive way to assess left ventricular diastolic pressure. This study only wants
to take part in finding other parameters in determining diastolic function. With the rationale
examination (Anderson et al, 2002), this study aimed to tested MAPSE as one of the
parameters for determining the left ventricle systolic function in addition to other parameters
function determination algorithm with good systolic function according to ASE guideline
2016 by making E /e' value as the main reference. Meanwhile, the MAPSE examination was
performed by placing the M-mode cursor on the mitral annulus in septal, lateral, inferior, and
anterior and the mean values are taken. Furthermore, a statistical test was performed to obtain
the value of the point of intersection and obtained the value of sensitivity, specificity, positive
age (p <0.001). The thickness of the septal wall when both systolic and diastolic have
significant differences in the study and control subjects (P = 0.002). There was no significant
difference in the dimensions of the left ventricle, left atrium dimension, or aortic annulus.
While the E and A ratios experienced significant differences between control and sample (p
In the statistical test results with ROC curve obtained the number 13.625 on the
under the curve area 0.635 as a cutoff point with a sensitivity of 62.5% and specificity 51.2%
(p <0.05).
The correlation between mean MAPSE and diastolic function was tested by
bivariate analysis using Pearson method and obtained coefficient value 0.242 which has a
Table 2. Sensitivity and specificity of mean MAPSE and impaired diastolic function
Cut off
Normal Impaired
mean p-
diastolic diastolic AUC Sens Spes ND+ ND
MAPSE value
function function
(mm)
>13.625 25(62.5) 20(48.8) 0.037 0.635 62.5% 51.2% 58.3% 55.5%
<13.625 15(37.5) 21(51.2)