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Background: Dyssynchrony is reportedly present in some patients with heart failure and normal ejection fraction (HFNEF) at rest. However, it is unknown if dyssynchrony is present on exercise and affects myocardial function when the patient is symptomatic.Method: 72 Patients (age 73±7years, 48 female) with exertional dyspnea and normal LV ejection fraction (60±7%) and 38 age-matched healthy controls (age 71±7years, 29 female, EF 63±7%) underwent cardiopulmonary exercise testing and full Doppler 2D-echocardiography at rest and on supine exercise. Analysis of three plane motion was performed using speckle tracking imaging with customized interpolation software. Standard deviation (SD) of peak event timing and time delay of diastolic motions were calculated to assess synchrony.Results: The standard deviation of time to peak basal rotation, peak apical rotation, peak longitudinal and radial displacements was not different at rest (48.6±32.9ms vs. 43.1±25.3ms, p=0.38). On exercise healthy controls were able to synchronize all myocardial motions as shown by a significantly reduced SD of 25.9±15.5ms whereas patients showed almost no decrease (40.1±27.2ms) suggesting the inability of the different muscle planes to contract cohesively at peak motion during exercise. Furthermore, the ratio of untwist and longitudinal extension during IVRT showed a significant steeper slope on exercise in patients indicating the presence of diastolic dyssynchrony.Conclusion: Systolic and diastolic dyssynchrony in all three planes are present on exercise in HFNEF patients. This contributes to the overall deterioration of LV systolic function and impaired early diastolic filling causing reduced stroke volume and high filling pressures on exercise, the symptoms and exercise limitation.