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LV twist has a key role in maintaining left ventricular (LV) contractility during exercise. The purpose of this study was to investigate LV torsion instead of twist as a surrogate marker of peak oxygen uptake (peak V̇O 2 ) assessed by cardiopulmonary exercise testing (CPET) in patients with non-ischemic dilated cardiomyopathy (DCM).Methods and Results:We evaluated 45 outpatients with DCM (50±12 years, 24% females) with 3D speckle-tracking electrocardiography prior to CPET. LV torsion, LV ejection fraction (EF), LV diastolic function, LV global longitudinal (GLS) and circumferential (GCS) strain were quantified. A reduced functional capacity (FC) was defined as a peak V̇O 2 &lt;20 mL/kg/min. LV torsion correlated most strongly with peak V̇O 2 (r=0.76, P&lt;0.001). LV torsion instead of twist was an independent predictor of peak V̇O 2 (B: 0.59 to 0.71, P&lt;0.001) in multivariable analyses. Impaired LV torsion &lt;0.61 degrees/cm was able to predict a reduced FC with higher sensitivity and specificity (0.91 and 0.81; area under the curve (AUC): 0.88, P&lt;0.001) than LV EF, GLS or GCS (AUC 0.64, 0.63 and 0.66; P&lt;0.05 for differences in AUC).

Three-Dimensional Left Ventricular Torsion in Patients With Dilated Cardiomyopathy ― A Marker of Disease Severity ―