Elagha, Abdalla

Fuisz, Anthon

Journal of Cardiovascular Magnetic Resonance

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Abdalla Elagha

Anthon Fuisz

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Mitral valve E-Point to Septal Separation (EPSS) measurement by cardiac magnetic resonance Imaging as a quantitative surrogate of Left Ventricular Ejection Fraction (LVEF)

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POSTER PRESENTATION Open Access
Mitral valve E-Point to Septal Separation (EPSS)
measurement by cardiac magnetic resonance
Imaging as a quantitative surrogate of Left
Ventricular Ejection Fraction (LVEF)
Abdalla Elagha1,2*, Anthon Fuisz1
From 15th Annual SCMR Scientific Sessions
Orlando, FL, USA. 2-5 February 2012
Summary
The EPSS measurement by cardiac MRI is an easy and
feasible method, which allows parallel assessment of LV
function, in patient with and without myocardial
fibrosis.
Background
Using Echocardiography, the mitral Valve E-Point to
Septal Separation (EPSS) is a straightforward approach
that roughly corresponds to the status of left ventricular
(LV) function, but its use has been limited to echocar-
diography and without solid quantitative correlation to
left ventricular ejection fraction (LVEF). It may also
cause underestimation of EF due to endocardial echo
dropout. Cardiac MRI (CMR) has a better spatial resolu-
tion than echocardiography, and is characterized by
superior endocardial border definition, facilitating more
accurate assessment of structural borders. The MRI
LVEF by Simpson’s method is widely considered the
most accurate and most reliable method for quantifying
the LVEF. Assessment of EPSS by CMR seems very
attractive and simple measurement, which can be an
additional standard tool in clinical MRI report for quan-
titative evaluation of LV function. Our objective was to
test the feasibility of measuring EPSS by CMRI, and its
quantitative correlation with LVEF measured by MRI
Simpson’s method in heterogeneous patient groups.
Methods
We studied a total of 143 patients, who underwent a full
CMR study. Nineteen patients with significant aortic
insufficiency, mitral stenosis/prosthesis, or septal hyper-
trophy were excluded. Short-axis cross-sectional stack
images were used to estimate LVEF by Simpson’s
method. The EPSS was determined using image plane
corresponding to a 3-chamber view, known as LVOT
view. The EPSS was measured in millimeters (mm) as
the minimal separation distance between the mitral
valve anterior leaflet and the ventricular septum, usually
occurring at the maximal filling phase of cardiac cycle
(Figure 1a). Cautious tracking of the leaflet through dia-
stole, frame by frame, allows measurement of shortest
distance between leaflet tip and the interventricular sep-
tum. Furthermore, we divided patients into two groups
according to presence or absence of fibrosis on delayed
hyperenhancement (DHE) MRI study.
Results
The LVEF ranged from 12-79 %. The EPSS ranged from
2.2-26.1 mm. We used correlation and linear regression
analysis to analyze the relation between the LVEF and
the EPSS. Correlation coefficient revealed to be very
strong (r= -0.92; 95% Confidence interval for r= -0.95 to
-0.87) with high significant level (P<0.0001). Using
regression analysis, MRI LVEF could be estimated from
the following equation (LVEF = 78.1569 - (2.6661 x
EPSS)), with strong regression coefficient (r2= 0.86).(Fig-
ure 1b).
Also, correlation and regression coefficients were
found to be closely similar in both groups with and
1Cardiac MRI, Washington Hospital Center, Washington DC, DC, USA
Full list of author information is available at the end of the article
Elagha and Fuisz Journal of Cardiovascular Magnetic Resonance 2012, 14(Suppl 1):P154
http://www.jcmr-online.com/content/14/S1/P154
© 2012 Elagha and Fuisz; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
without DHE fibrosis (r= -0.94 with no fibrosis, r= -0.91
with fibrosis; P<0.0001 for both groups).
Conclusions
The EPSS measurement by cardiac MRI is an easy and
reliable method, which allows parallel assessment of LV
function, in patient with and without myocardial fibro-
sis. The EPSS can generate a rapid quantitative idea on
LV function, especially when acquisition of multiple
breath-hold short-axis images is difficult.
Figure 1 (a) Top: Measurement of EPSS in 3-chamber view (cine SSFP image). The mitral valve E-septal separation measured 7.1mm (upper left)
and 26.1 mm( upper right), as shown by the line representing the minimal separation distance between the mitral valve anterior leaflet tip and
the ventricular septum. The E.F. was 59 % and 12%; respectively . (b) Bottom: Scatter diagram of the MRI LVEF vs.the EPSS with regression line
(solid line) and 95% confidence intervals (dotted lines).
Elagha and Fuisz Journal of Cardiovascular Magnetic Resonance 2012, 14(Suppl 1):P154
http://www.jcmr-online.com/content/14/S1/P154
Page 2 of 3
Funding
Washington Hospital Center.
Author details
1Cardiac MRI, Washington Hospital Center, Washington DC, DC, USA.
2Cardiology Department, Cairo Univesrsity Hospitals, Cairo, Egypt.
Published: 1 February 2012
doi:10.1186/1532-429X-14-S1-P154
Cite this article as: Elagha and Fuisz: Mitral valve E-Point to Septal
Separation (EPSS) measurement by cardiac magnetic resonance
Imaging as a quantitative surrogate of Left Ventricular Ejection Fraction
(LVEF). Journal of Cardiovascular Magnetic Resonance 2012 14(Suppl 1):
P154.
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Table 1 Correlation between EF range value measured by
cardiac MRI and EPSS range distance.
LVEF EPSS range (mm)
Normal ( ≥ 60 %) ≤ 7.3
Low normal (55-59 %) 7.4-8.9
Mild systolic dysfunction (40-54%) 9-13.9
Moderate systolic dysfunction (30-39%) 14-17.1
Severe systolic dysfunction (< 30%) >17.1
Elagha and Fuisz Journal of Cardiovascular Magnetic Resonance 2012, 14(Suppl 1):P154
http://www.jcmr-online.com/content/14/S1/P154
Page 3 of 3


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Mitral valve E-Point to Septal Separation (EPSS) measurement by cardiac magnetic resonance Imaging as a quantitative surrogate of Left Ventricular Ejection Fraction (LVEF)

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