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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 7367 years, 48 female) with breathlessness on exertion and normal EF (6067%) underwent cardiopulmonary exercise test to rule out alternative clinical reasons (VO 2 max 18.464.9 ml/min/kg). Data were compared to 38 age-matched control subjects (age 7167 years, 29 female, EF 6367%) with a normal exercise tolerance (VO 2 max 28.665.1 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.

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