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3/31/2015
New Echocardiogram Index
Alternatives to
Mapse and Tapse Z-Scores
in Children
Ziad Issa MD, Ziad Bulbul MD, Giovanni Di Salvo MD,
Nasser Moiduddin MD
The Heart Centre
King Faisal Specialist Hospital and Research Centre
LV-Background I
• LV has traditionally been evaluated by radial
shortening
• LV has both sub endocardial and sub epicardial
longitudinal fibers surrounding a middle layer
of circumferential fibers
• LV longitudinal function is important in heart
failure, mitral valve replacement, left ventricle
hypertrophy, and aortic stenosis
1. Wenzelburger FWG, Tan YT, Choudhary FJ, Lee ESP, Leyva F, Sanderson JE. Mitral annular plane systolic excursion on
exercise: a simple diagnostic tool for heart failure with preserved ejection fraction. Eur J Heart Fail. 2011;13(9):953-60.
doi:10.1093/eurjhf/hfr081.
2. Lisi M, Ballo P, Cameli M, et al. Mitral annular longitudinal function preservation after mitral valve repair: the MARTE
study. Int J Cardiol. 2012;157(2):212-5. doi:10.1016/j.ijcard.2010.12.054.
3. Jones CJ, Raposo L, Gibson DG. Functional importance of the long axis dynamics of the human left ventricle. Br Heart J.
1990;63(4):215-20. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1024433&tool=pmcentrez&rendertype=abstract. Accessed
September 14, 2014.
4. Lam Y-Y, Bajraktari G, Lindqvist P, et al. Prolonged total isovolumic time is related to reduced long-axis functional
recovery following valve replacement surgery for severe aortic stenosis. Int J Cardiol. 2012;159(3):187-91.
doi:10.1016/j.ijcard.2011.02.050.
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LV-Background II
• MAPSE, mitral annular plane systolic excursion
is a sensitive, reproducible, and relative load
independent index of LV longitudinal function
• Few normal values exist in children
• Kostenberger et al, published z-scores for
MAPSE indicating age, height, and BSA have an
effect
5.Koestenberger M, Nagel B, Ravekes W, et al. Left ventricular long-axis function: reference values of the mitral annular plane
systolic excursion in 558 healthy children and calculation of z-score values. Am Heart J. 2012;164(1):125-31.
doi:10.1016/j.ahj.2012.05.004.
Am Heart J. 2012 Jul;164(1):125-31. doi: 10.1016/j.ahj.2012.05.004. Epub 2012 Jun 20.
Left ventricular long-axis function: reference values of the mitral annular plane
systolic excursion in 558 healthy children and calculation of z-score values.
Koestenberger M1, Nagel B, Ravekes W, Avian A, Heinzl B, Fritsch P, Fandl A, Rehak T, Gamillscheg A.
Author information
Abstract
BACKGROUND:
Longitudinal myocardial function has gained more interest in the last years. The mitral annular plane systolic
excursion (MAPSE) is an echocardiographic measurement to assess left ventricular (LV) long-axis function in
adults. The aim of this study was to evaluate MAPSE values in a healthy pediatric population and to propose
reference values.
METHODS:
A prospective study was conducted in a group of 558 healthy children and adolescents (age day 1 to 18 years)
(body surface area [BSA] 0.18-2.21 m(2)). We determined the effects of age and BSA on MAPSE values and a
possible correlation of MAPSE values with LV ejection fraction values.
RESULTS:
The MAPSE ranged from a mean of 0.57 cm (z-score ±2: 0.38-0.76 cm) in neonates to 1.63 cm (z-score ±2:
1.31-1.95 cm) in 18-year-old adolescents. The MAPSE values showed a positive correlation with age (r = 0.87,
P < .001) and BSA (r = 0.89, P < .001) with a nonlinear course. There was no significant difference in MAPSE
values between females or males. A positive correlation was found between MAPSE values and LV ejection
fraction values (r = 0.28, P < .001).
CONCLUSIONS:
Z-scores of MAPSE values were calculated, and percentile charts were established to serve as reference data
in patients with congenital heart disease or heart failure in the future.
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RV Background
• Often evaluated subjectively in children
• There is no standard measurement for RV function given
the complex geometry
• RV consists mostly of longitudinal fibers
• DTI, TAPSE, RV MPI, 2-dimensional speckle tracking
strain, Velocity vector imaging all have been used
• TAPSE is better reproducible echo parameter for RV
assessment
• Respective Z-scores have been published in 640 children,
by Kostenberger et al.
6. .Forfia PR, Fisher MR, Mathai SC, et al. Tricuspid annular displacement predicts survival in pulmonary
hypertension. Am J Respir Crit Care Med. 2006;174(9):1034-41. doi:10.1164/rccm.200604-547OC.
7. Koestenberger M, Ravekes W, Everett AD, et al. Right ventricular function in infants, children and
adolescents: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy
patients and calculation of z score values. J Am Soc Echocardiogr. 2009;22(6):715-9.
doi:10.1016/j.echo.2009.03.026.
J Am Soc Echocardiogr. 2009 Jun;22(6):715-9. doi: 10.1016/j.echo.2009.03.026. Epub 2009 May 7.
Right ventricular function in infants, children and adolescents: reference values of
the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy patients and
calculation of z score values.
Koestenberger M1, Ravekes W, Everett AD, Stueger HP, Heinzl B, Gamillscheg A, Cvirn G, Boysen A, Fandl A, Nagel B.
Author information
Abstract
BACKGROUND:
Tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement to assess right
ventricular systolic function in adults. The aim of this study was to determine growth-related changes in TAPSE
to establish references values.
METHODS:
A prospective study was conducted in a group of 640 healthy pediatric patients (age range, 1 day to 18 years;
body surface area range, 0.12-2.25 m(2)). The effects of age and body surface area on TAPSE were
determined.
RESULTS:
TAPSE ranged from a mean of 0.91 cm (z score +/- 3, 0.56-1.26 cm) in neonates to 2.47 cm (z score +/- 3,
1.84-3.10 cm) in 18-year-olds. TAPSE values showed positive correlations with age and body surface area.
There was no significant difference in TAPSE values between female or male children.
CONCLUSION:
In this study, z scores of TAPSE values were calculated and percentile charts were established to serve as
reference data for ready application in patients with congenital heart disease in the future.
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• MAPSE z-score and TAPSE z-score are
inconvenient in clinical echo and correlation to
other measures are not clear
• For other echocardiographic measures
software is proprietary, complicated, time
consuming, and sometimes limited by image
acquisition
OUR STUDY
• LSI- LV longitudinal systolic index, which is annular
displacement from M-mode echocardiography divided
by endocardial LV length
• RSI- RV longitudinal systolic index, which is annular
displacement from M-mode echocardiography divided
by endocardial LV length
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Hypothesis
• Novel indexes of left ventricle longitudinal systolic
index (LSI) and right ventricle longitudinal systolic
index (RSI) nullify the need for z-scores.
• They also compare favourably to longitudinal indices
such as global strain.
Methods
• Consecutive patients with normal anatomy
except for tiny patent foramen ovale or small
patent ductus arteriosus with an ejection
fraction from 55 to 75%
• Retrospective IRB approved review of patients
from day of life one to fourteen years of age at
King Faisal Specialist Hospital and Research
Centre from 2009 to 2011.
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Echocardiograms
• IE33, Philips echo machine were used by
sonographers to acquire m-mode interrogation of
the mitral valve annulus and tricuspid valve
annulus displacement as part of routine clinical
evaluation
• (ZI) ensured image quality and to ensure the LV
was not foreshortened
• Traditional measurements included LV
dimensions and ejection fraction by m-mode
Echo Examples
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Data Collection II
• Data presented as mean +/- sd
• Values for Echo indices: Mapse, Tapse, LV
length, EF from m-mode, & demographics:
age, BSA, weight, height, gender, and heart
rate recorded.
• LSI and RSI were calculated
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Data Collection III
• Mapse and Tapse z-scores calculated using
published data of Kostenberger
• LSI and RSI correlated to LV EF, RV FAC, mapse,
mapse (z), tapse, tapse (z), gender, and linear
regression for HR, age, and BSA.
• A two-tailed p value <0.05 was significant, spss
(chicago) was used for data analysis
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Subject Characteristics
N=201
N ± SD
Age
1856.6 ± 1763.2 days
Females
93
BSA
0.67 ±0.4 meters squared
Weight
18.3 ± 16.2 kg
Heart rate
107 ± 27 bpm
LVEF, m-mode
67.3 ± 5.1 %
LVEF, Simpsons
55.9 ± 8.6 %
LV length
51.7 ± 16.1 mm
MAPSE
10.4 ± 3.3 mm
MAPSE z-score
-0.07 ± 1.2
LSI (MAPSE/LV length)
0.20 ± 0.03
TAPSE
17.4 ± 5.4 mm
TAPSE z-score
0.7 ± 1.7
RSI (TAPSE/LV length)
0.34 ± 0.06
R=0.86
R=0.73
R=0.81
R=0.8
p< 0.001
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R=0.84
R=0.76
R=0.74
R=0.66
p<0.001
Age
R=0.8, p<0.001
R=0.11, p=0.1
R=0.74, p<0.001
R=0.16, p=0.02
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RSI and Age Stratification
BSA
R=0.81, p<0.001
R=0.11, p=0.1
R=0.76, p<0.001
R=0.13, p=0.07
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R=0.7, p<0.001
R=0.74, p<0.001
R=0.02, p=0.74
R=0.03, p=0.67
Gender
P=0.78, r=-0.02
P=0.38, r=0.06
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Height
Weight
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LSI vs MAPSE and MAPSE (z)
r =0.73, p<0.001
r= 0.35, p<0.001
RSI vs TAPSE,
RSI vs TAPSE and TAPSE (z)
r = 0.76, p<0.001
r =0.42, p<0.001
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LVEF and LSI, Mapse, Mapse z-score
RSI, Tapse (z) and RV FAC
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Discussion- Function
• Traditional LV function by radial motion, RV function by
the eyeball but the key is longitudinal function
• Kostenberger et al, in 558 children alluded that mitral
displacement is affected by LV longitudinal displacement
• MAPSE has been shown to evaluate cardiac pathology
– Increased in post mitral valve regurgitation repair
– Decreased in post tetralogy of Fallot repair along with Tapse
-Lisi M, Ballo P, Cameli M, et al. Mitral annular longitudinal function preservation after mitral valve
repair: the MARTE study. Int J Cardiol. 2012;157(2):212-5. doi:10.1016/j.ijcard.2010.12.054.
-Riesenkampff E, Mengelkamp L, Mueller M, et al. Integrated analysis of atrioventricular interactions in
tetralogy of Fallot. Am J Physiol Heart Circ Physiol. 2010;299(2):H364-71.
doi:10.1152/ajpheart.00264.2010.
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Discussion- DTI
• Roberson and Cui, evaluated annular
displacement index
– Similarly hr, age, gender, and bsa had no effect on
the tissue doppler displacement index and obviated
the need for DTI mitral annular s’z-score
– They found DTI displacement index similar to mean
Lagrangian strain values in children
– Our study simplifies it to an m-mode evaluation on
both Mapse and Tapse
J Am Soc Echocardiogr. 2009 Apr;22(4):376-82. doi: 10.1016/j.echo.2009.01.008. Epub 2009 Mar 9.
Tissue Doppler imaging measurement of left ventricular systolic function in children: mitral annular
displacement index is superior to peak velocity.
Roberson DA1, Cui W.
Discussion-LSI
• LSI ranged from 0.20 +/- 0.03
• If LSI is multipled by -100, you get similar strain values.
• Our sample of 27 patients, showed significant
correlation between LV free wall and LSI
• Published values: -24+/- 2.9% in adults, and meta
analysis in children: -15.9 to -22.1%.
• Like much of the literature LSI, Mapse does not
correlate with LV EF by mmode or simpsons
Yingchoncharoen T, Agarwal S, Popović ZB, Marwick TH. Normal ranges of left ventricular strain: a
meta-analysis. J Am Soc Echocardiogr. 2013;26(2):185-91. doi:10.1016/j.echo.2012.10.008.
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Mitral annular longitudinal function preservation after
mitral valve repair: The MARTE study
M. Lisi, P. Ballo, M. Cameli, F. Gandolfo, M. Galderisi, M. Chiavarelli, M.Y. Henein, S. Mondillo
Received: October 13, 2010; Accepted: December 8, 2010; Published Online: January 03, 2011
Abstract
Background
In patients with chronic mitral regurgitation (MR), undergoing surgical mitral valve repair, current Guidelines only
recommend standard echocardiographic indices i.e. left ventricular (LV) ejection fraction (EF), and LV end-systolic and
end-diastolic diameters as preoperative variables. However LV EF is often preserved until advanced stages of the valve
disease. Aim of this study was to evaluate changes in LV systolic longitudinal function, 3 months after mitral valve repair
in patients with chronic degenerative MR and normal preoperative EF.
Methods
We measured M-mode mitral lateral annulus systolic excursion (MAPSE) and Tissue Doppler (TD) peak systolic annular
velocity (Sm) in 31 patients with moderate to severe MR and normal EF (59.9±4.7%) candidates for mitral valve repair,
preoperatively and 3 months after surgery.
Results
After mitral valve repair, Sm increased from 7.8±1.4 to 9.6±2.2 cm/s (p<0.0001) and MAPSE increased from 1.33±0.26 to
1.55±0.25 cm (p=0.0013). EF decreased from 59.9±4.7 to 51.3±5.9% (p<0.0001). As expected, LV diameters and
volumes, wall thicknesses, midwall fractional shortening (mFS), and left atrial (LA) size were all reduced after surgery.
Conclusions
This study suggests that assessment of LV long axis systolic velocity and amplitude of excursion by echocardiography is
more sensitive than simple determination of EF for revealing the beneficial impact of MR surgery on overall systolic
function.
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Discussion-RSI
• Although RSI has no association with BSA or gender it
is affected by age.
• If the first 2 months are noted to be associated by age
and young adulthood, then RSI is from 0.34+/- 0.06,
• These values are similar to meta analysis of 10 studies
among 225 children revealing -26.5 to -31.5 % as
strain values, albeit higher likely to not incorporate the
interventricular septum
• RSI does not seem to correlate with RV FAC
J Am Soc Echocardiogr. 2013 Nov;26(11):1322-9. doi: 10.1016/j.echo.2013.06.022. Epub 2013 Aug 6.
Tricuspid annular plane systolic excursion in the assessment of right ventricular function in children and
adolescents after repair of tetralogy of Fallot.
Mercer-Rosa L1, Parnell A, Forfia PR, Yang W, Goldmuntz E, Kawut SM.
Author information
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J Am Soc Echocardiogr. 2013 Nov;26(11):1322-9. doi: 10.1016/j.echo.2013.06.022. Epub 2013 Aug 6.
Tricuspid annular plane systolic excursion in the assessment of right ventricular
function in children and adolescents after repair of tetralogy of Fallot.
Mercer-Rosa L1, Parnell A, Forfia PR, Yang W, Goldmuntz E, Kawut SM.
Author information
Abstract
BACKGROUND:
Assessing right ventricular (RV) performance is essential for patients with tetralogy of Fallot (TOF). The aim of
this study was to investigate the reliability and validity of tricuspid annular plane systolic excursion (TAPSE)
against cardiac magnetic resonance imaging measures and cardiopulmonary exercise testing.
METHODS:
A retrospective study was performed in 125 outpatients with repaired TOF with available protocol-driven
echocardiography, cardiac magnetic resonance imaging, and exercise stress testing obtained as part of a
cross-sectional study. TAPSE was measured on the two-dimensional apical four-chamber view on
echocardiography by two readers. Multivariate linear regression was used to examine the association between
TAPSE and measures of RV function and exercise capacity.
CONCLUSIONS:
TAPSE is reproducibly measured by echocardiography in patients with TOF. It is not associated with RV
ejection fraction or exercise performance, and its association with RV stroke volume may be confounded by
body size. On the basis of these results, TAPSE is not representative of global RV performance in patients with
TOF.
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Limitations
• Our study of indexed Mapse, (LSI) and indexed Tapse, (RSI) is
subject to angle dependency although correctible by technique.
• Our study does not compare LSI to stronger methods of
evaluating LV function such as CMR, 3 dimensional speckle
tracking analysis, or cath hemodynamics.
• Our study does not compare RSI to stronger methods of
evaluating RV function such as CMR, 2 dimensional or 3
dimensional RV strain.
• We did not control for sedation status or gate for respiration
potentially confounding results.
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Conclusion I
• We demonstrated the LSI is a reliable indexed
measure of longitudinal function not requiring
z-scores.
• Normal values for LSI are provided
• LSI is not associated with age, gender, heart
rate, or body surface area
• LSI can be used to infer LV global longitudinal
strain values
Conclusion II
• RSI is an indexed measure of TAPSE that offers an
additional reliable non z-score method to
evaluate RV longitudinal function
• RSI can infer RV global longitudinal strain,
although head to head comparison needs to be
done
• Further studies using LSI and RSI in abnormal
congenital heart lesions with rigorous LV and RV
function indices are warranted
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Abstract
• Background: Mitral annular plane systolic excursion (MAPSE), and tricuspid
annular plane systolic excursion (TAPSE) are relatively load independent
measurements of longitudinal (LV) left ventricle and (RV) right ventricle
function. Longitudinal function is increasingly important. Normal paediatric
values of MAPSE and TAPSE unlike adults are based on z-scores. Z-scores are
inconvenient and relation to strain is unknown. We hypothesize novel
indexes of left ventricle longitudinal systolic index (LSI) and right ventricle
longitudinal systolic index (RSI) nullify the need for z-scores and compare
favourably to longitudinal indices such as global strain.
• Methods: Normal echocardiograms were retrospectively reviewed from 2009
to 2011. Ejection fraction, LV dimensions, MAPSE, and TAPSE were
determined. LSI and RSI are ratios of MAPSE and TAPSE divided by LV length
respectively. Correlations were done between echocardiogram indices.
Values of RSI and LSI were compared to RV and LV global strain.
Abstract
• Results: Two hundred and one patients had normal ejection fractions
(67.3 ± 5.1 %). Mean MAPSE 10.4 ± 3.3 mm, z-score -0.07 ± 1.2, and
LSI 0.20 ± 0.03; Mean TAPSE 17.4 ± 5.4 mm, z-score 0.74 ± 1.7, and
RSI 0.34 ± 0.06. LSI and MAPSE z-scores correlated, r=0.73, p <0.001.
RSI and TAPSE z-scores correlated with r=0.76, p <0.001. Age, gender,
heart rate, and BSA did not correlate with LSI. Age influences RSI, r=0.16, p=0.02. Heart rate, BSA, and gender do not.
• Conclusion: We determined that LSI is a reliable longitudinal measure
of longitudinal left ventricular function that does not require z-scores.
RSI is an additional reliable measure of longitudinal right ventricle
function. We provide normal values for LSI and RSI. Age, heart rate,
BSA, and gender do not affect LSI. Age does influence RSI in the first
few months. LSI can infer LV global longitudinal strain values. RSI can
infer RV global longitudinal strain. Further studies using LSI and RSI
on abnormal congenital heart lesions are warranted.
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Acknowledgements
• Thousand Thank You-s to our often underappreciated Echosonographers:
Mr. Syed Yousuf Mohiuddin
Mrs. Aisha Janas Khan
Mrs. Josefa Cangas Paredes
Mrs. Roma Genove Jurado
Mrs. Mirasol Panucial Pernia
Mrs. Shaima Hasan Alattas
Mrs. Samra Fahad
Mr. Abdulmohsen Eid Alrowais
Acknowledgements
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Special Thanks:
Dr. Jehad Al Buraiki
Dr. Majid Al Fayyadh
Dr. Ziad Issa
Dr. Ziad Al Bulbul
Dr. Giovanni Di Salvo
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END
THANK YOU
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