Background The pathophysiology of heart failure with normal ejection fraction (HFNEF) is complex and not fully understood. Recent publications showed a loss of apical rotation and longitudinal function particularly on exercise in these patients. Whether a deterioration of basal rotation and a dyssynchrony of different three plane motions on exercise might contribute to symptoms in these patients is not known.

Method 72 Patients (age 73±7 years, 48 female) with breathlessness on exertion and normal EF (60±7%) underwent cardiopulmonary exercise test to rule out alternative clinical reasons (VO₂max 18.4±4.9 ml/min/kg). Data were compared to 38 age-matched control subjects (age 71±7 years, 29 female, EF 63±7%) with a normal exercise tolerance (VO₂max 28.6±5.1 ml/min/kg). All underwent full Doppler 2D-echocardiography at rest and on supine exercise. Echo images were analysed off-line. Apical and basal rotation, longitudinal and radial displacement were measured by speckle tracking. Speckle tracking pictures and colour TDI curves were loaded into custom made software. The software interpolated all curves and calculated twist as the difference of rotation at apex and at base. The software offered timing information to calculate SD and time delays for different motions.

Results As previously described apical rotation was reduced at rest and on exercise Basal rotation was comparable at rest but significantly reduced on exercise in patients. The SD for four different systolic peak motions (basal and apical rotation, longitudinal and radial displacement) was comparable at rest but on exercise controls showed a significantly reduced SD compared to patients showing a greater ability to synchronise motions. Furthermore a ratio of untwist during IVRT and longitudinal extension (Ratio Untwist /Extension in IVRT) showed a significant deeper slope on exercise for patients indicating a loss of synchrony in diastole, too. All results are presented in Abstract 81 table 1.

Conclusion Patients with HFNEF show a deterioration of basal rotation and a systolic and diastolic three plane dyssynchrony particularly on exercise. This might further contribute to the deterioration of early diastolic suction and therefore decrease stroke volume on exercise. This might be a major contribution to their symptoms.