BACKGROUND: Myocardial strain is a valuable biomarker for diagnosing and predicting cardiac conditions, offering additional prognostic information to traditional metrics like ejection fraction. While cardiovascular magnetic resonance (CMR) methods, particularly cine displacement encoding with stimulated echoes (DENSE), are the gold standard for strain estimation, evaluation of regional strain estimation requires precise ground truth. This study introduces DENSE-Sim, an open-source simulation pipeline for generating realistic cine DENSE images with high-resolution known ground truth strain, enabling evaluation of accuracy and precision in strain analysis pipelines. METHODS: This pipeline is a modular tool designed for simulating cine DENSE images and evaluating strain estimation performance. It comprises four main modules: 1) anatomy generation, for creating end-diastolic cardiac shapes
2) motion generation, to produce myocardial deformations over time and Lagrangian strain
3) DENSE image generation, using Bloch equation simulations with realistic noise, spiral sampling, and phase-cycling
and 4) strain evaluation. To illustrate the pipeline, a synthetic dataset of 180 short-axis slices was created, and analysed using the commonly-used DENSEanalysis tool. The impact of the spatial regularization parameter (k) in DENSEanalysis was evaluated against the ground-truth pixel strain, to particularly assess the resulting bias and variance characteristics. RESULTS: Simulated strain profiles were generated with a myocardial SNR ranging from 3.9 to 17.7. For end-systolic radial strain, DENSEanalysis average signed error (ASE) in Green strain ranged from 0.04 ± 0.09 (true-calculated, mean ± std) for a typical regularization (k=0.9), to - 0.01 ± 0.21 at low regularization (k=0.1). Circumferential strain ASE ranged from - 0.00 ± 0.04 at k=0.9 to - 0.01 ± 0.10 at k=0.1. This demonstrates that the circumferential strain closely matched the ground truth, while radial strain displayed more significant underestimations, particularly near the endocardium. A lower regularization parameter from 0.3 to 0.6 depending on the myocardial SNR, would be more appropriate to estimate the radial strain, as a compromise between noise compensation and global strain accuracy. CONCLUSION: Generating realistic cine DENSE images with high-resolution ground-truth strain and myocardial segmentation enables accurate evaluation of strain analysis tools, while reproducing key in vivo acquisition features, and will facilitate the future development of deep-learning models for myocardial strain analysis, enhancing clinical CMR workflows.