Lin TT; University College of Medicine and Hospital, Taipei,Taiwan.
Huang KC; Lin HH; Su MM; Lin LC; Lin LY; Wu CK

European Radiology. 36(2):1146-1157, 2026 Feb.

OBJECTIVES: To investigate the role of right ventricular (RV) maladaptive
response to increased afterload in the early diagnosis of heart failure
with preserved ejection fraction (HFpEF) using cardiac magnetic resonance
(CMR) and invasive cardiopulmonary exercise testing (iCPET). This study
evaluates biventricular function and its association with exercise
performance in HFpEF.

MATERIALS AND METHODS: We prospectively recruited 145 patients with
suspected HFpEF from two centers, of whom 113 underwent echocardiography,
iCPET, and CMR. Patients met the 2016 European Society of Cardiology HFpEF
criteria, with iCPET confirming HFpEF as a pulmonary capillary wedge
pressure (PCWP) > 15 mmHg at rest and > 25 mmHg at peak exercise. The
diagnostic performance of CMR parameters was assessed using the area under
the curve (AUC).

RESULTS: Among the 113 patients, 72 had HFpEF (68 +/- 10 years) and 41
were non-HFpEF (66 +/- 11 years). HFpEF patients exhibited significantly
reduced resting pulmonary artery compliance. CMR-derived RV longitudinal
strain and left atrial (LA) reservoir strain had the highest diagnostic
accuracy for HFpEF (AUC 0.805 and 0.776, respectively). A sex disparity
was observed in the LA reservoir strain’s diagnostic performance, with
higher accuracy in males (AUC 0.801) compared to females (AUC 0.559).
Additionally, impaired LA reservoir and booster strains, correlated with
reduced exercise capacity and increased PCWP during exercise, highlighting
their clinical relevance.

CONCLUSIONS: RV systolic dysfunction and impaired LA strain serve as
early HFpEF markers. The more pronounced LA dysfunction in males suggests
potential sex-specific differences, underscoring the need to integrate RV
and LA strain assessment into HFpEF diagnostics and personalized treatment
approaches.

KEY POINTS: Question Can cardiac MRI (CMR)-derived RV strain and LA
reservoir strain improve the early diagnosis of HFpEF in symptomatic
patients with preserved ejection fraction? Findings CMR-derived RV
longitudinal strain and LA reservoir strain effectively differentiate
early HFpEF; diagnostic accuracy of LA strain varies significantly by sex.
Clinical relevance CMR-based RV and LA strain measurements enhance early
HFpEF detection, with higher diagnostic accuracy in males, supporting
sex-specific diagnostic strategies for timely and personalized heart
failure care.