Clinical efficacy, safety, tolerability, and survival outcome of long-term inhaled iloprost treatment in the management of pulmonary arterial hypertension: Data from prospective multicenter observational OPTION study.

OBJECTIVE: To evaluate clinical efficacy, safety and tolerability of long-term inhaled iloprost treatment in the daily practice for the management of pulmonary arterial hypertension (PAH). METHODS: A total of 115 patients with PAH on inhaled iloprost treatment were included. New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and 6-minute walk distance (6MWD) were recorded at baseline and at 3rd to 24th month visits. Safety and tolerability of iloprost treatment were also evaluated during follow-up, as were the survival, clinical worsening, and the related risk factors. RESULTS: The treatment was associated with an increase in the percentage NYHA functional class II (from 0.0% at enrolment to 36.2% at 24th month visit) patients but no significant difference was noted in 6MWD values. Clinical worsening was observed in 63.5% patients, while survival rate was 69.6%. NT-proBNP levels were significantly higher in non-survivors than in survivors (p=0.042). Cox regression analysis revealed the association of female sex [odds ratio (OR)=0.318; 95% confidence interval (CI), 0.128-0.792; p=0.014] and scleroderma-related PAH (OR=0.347; 95% CI, 0.140-0.860; p=0.022) with significantly lower risk (3.14 fold and 2.88 fold, respectively) of mortality. CONCLUSION: Our findings indicate favorable efficacy, safety, and tolerability of long-term iloprost treatment in the management of PAH, whereas improved NYHA functional class was not accompanied with a significant change in 6MWD values. Patient age was a risk factor for clinical worsening, while female sex, scleroderma subtype, and lower NT-proBNP levels were associated with significantly lower mortality risk.

The Effect of Smoking on Endothelial Dysfunction in Autosomal Dominant Polycystic Kidney Disease Patients with Preserved Renal Function.

BACKGROUND: In autosomal dominant polycystic kidney disease (ADPKD), endothelial dysfunction (ED) is common and occurs much earlier than kidney function impairment. The impact of smoking on ED in ADPKD patients has not been previously studied. The aim of this study was to investigate the potential contribution of smoking habits to ED and subclinical atherosclerosis in these patients. METHODS: This case-control study included 54 ADPKD patients with preserved renal function and 45 healthy control subjects. ED was assessed using ischemia-induced forearm flow-mediated dilatation (FMD). Carotid intima-media thickness (CIMT) was measured from 10 mm proximal to the right common carotid artery. Clinical demographic characteristics and laboratory data were recorded for the patients and control group. Regression analysis was used to determine independent associations of ED and CIMT. RESULTS: FMD was significantly lower in the ADPKD patients (19.5 ± 5.63 vs. 16.56 ± 6.41, p = .018). Compared with nonsmoker ADPKD patients, smoker patients had significantly lower FMD values (18.19 ± 6.52 vs. 13.79 ± 5.27, p = .013). In multiple regression analysis, age (ß = -0.294, 95% CI: -0.392: -1.96, p = .001) for FMD and smoking (ß = 1.328, 95% CI: 0.251, 2.404, p = .017) for CIMT were independent predictors. CONCLUSIONS: Patients with ADPKD had more impaired endothelial function and subclinical atherosclerosis compared with control subjects. Smoking may increase the risk of subclinical atherosclerosis in ADPKD patients.

Morning blood pressure surge in early autosomal dominant polycystic kidney disease and its relation with left ventricular hypertrophy.

INTRODUCTION: The activation of the sympathetic nervous system, which usually leads to a swift surge in blood pressure in the morning hours (MBPS) may be the cause of left ventricular hypertrophy (LVH) and endothelial dysfunction (ED) in early autosomal dominant polycystic kidney disease (ADPKD) patients. We studied the association between MBPS and LVH in ADPKD patients with preserved renal functions. METHODS: Patients with ADPKD with preserved renal functions were enrolled. Prewaking MBPS was calculated using ambulatory blood pressure monitoring. The patients were categorized as MBPS (≥median) and non-MBPS (

The association between cardiac valvular calcification and fetuin-A levels in kidney transplant recipients.

OBJECTIVES: Low fetuin-A levels in hemodialysis patients can be associated with development of vascular and valvular calcifications. The mechanisms underlying vascular and valvular calcifications are multifactorial. There are a few studies showing the relationship between low fetuin-A levels and valvular calcification after kidney transplantation. We aimed to evaluate the association between serum fetuin-A levels and valvular calcification in kidney transplant recipients. METHODS: The cardiac valvular calcification was assessed by echocardiography in 56 recipients. Patients were divided into two groups as those with (n = 11) and without (n = 45) aortic and/or mitral valve calcification. The extent of valvular calcification was visually assessed according to the standard visual score method: moderately (multiple larger spots) and heavily calcified (extensive thickening and calcification) of all cusps. Serum fetuin-A levels were measured. RESULTS: The demographic features of both groups were comparable. There was no significant difference between regular physical exercise (63.6% vs. 55.6%), obesity (18.2% vs. 17.8%), abdominal obesity (54.5% vs. 46.7%), smoking (0% vs. 13.3%), hypertension (63.6% vs. 68.9%), left ventricular hypertrophy (45.5% vs. 33.3%) and diabetes mellitus (9.1% vs. 20%) ratios in groups with or without valvular calcification, respectively (p > 0.05). Fetuin-A levels of both groups did not differ. Fetuin-A levels positively correlated with serum creatinine (r 0.326, p = 0.014), and negatively correlated with estimated glomerular filtration rate (r - 0.297, p = 0.026). CONCLUSIONS: We could not find a relationship between serum fetuin-A levels and valvular calcification in kidney recipients. In this population, further studies are needed to assess the role of serum fetuin-A in valvular calcification.

Serum paraoxonase activity in patients with ischaemic and nonischaemic dilated cardiomyopathy.

BACKGROUND: This study examined whether the serum PON1 activity is different in patients with ischaemic dilated cardiomyopathy (IDCM) and nonischaemic dilated cardiomyopathy (NDCM) and the relation between the serum PON1 activity and serum pro-BNP levels. METHODS AND RESULTS: In this study, we enrolled 60 patients with left ventricular systolic failure (New York Heart Association [NYHA] class III-IV) and a left ventricular ejection fraction (EF) < 40% as determined by echocardiography and 30 healthy subjects. The patients with systolic heart failure were divided into two groups: patients with IDCM and patients with NDCM. Blood samples were obtained to measure the serum PON1 activity and the serum pro-BNP levels. The median serum PON1 activities were lower among the patients with IDCM or with NDCM compared with the control subjects (p < .001, p = .043, respectively). Compared with the control subjects, the patients with IDCM or with NDCM had higher serum pro-BNP levels (p < .001, p < .001, respectively). The serum PON1 activity was negatively correlated with the serum pro-BNP levels in patients with IDCM (r = -0.548, p < .001). The area under the ROC curve of the serum PON1 activity was 0.798. Using a serum PON1 activity of 201.3 U/L as a cut-off value, the sensitivity was 86.84% and specificity was 66.67% for the diagnosis of IDCM. CONCLUSIONS: In this study, the serum PON1 activity was significantly reduced in the patients with IDCM or with NDCM compared with the control subjects. The serum PON1 activity of the patients with IDCM was negatively correlated with the serum pro-BNP levels.

Preliminary results from a nationwide adult cardiology perspective for pulmonary hypertension: RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG).

OBJECTIVE: The present study was designed to evaluate the characteristics of pulmonary hypertension (PH) and adult cardiology practice patterns for PH in our country. METHODS: We evaluated preliminary survey data of 1501 patients with PH (females, 69%; age, 44.8±5.45) from 20 adult cardiology centers (AdCCs). RESULTS: The average experience of AdCCs in diagnosing and treating patients with PH was 8.5±3.7 years. Pulmonary arterial hypertension (PAH) was the most frequent group (69%) followed by group 4 PH (19%), group 3 PH (8%), and combined pre- and post-capillary PH (4%). PAH associated with congenital heart disease (APAH-CHD) was the most frequent subgroup (47%) of PAH. Most of the patients' functional class (FC) at the time of diagnosis was III. The right heart catheterization (RHC) rate was 11.9±11.6 per month. Most frequently used vasoreactivity agent was intravenous adenosine (60%). All patients under targeted treatments were periodically for FC, six-minute walking test, and echo measures at 3-month intervals. AdCCs repeated RHC in case of clinical worsening (CW). The annual rate of hospitalization was 14.9±19.5. In-hospital use of intravenous iloprost reported from 16 AdCCs in CWs. Bosentan and ambrisentan, as monotreatment or combination treatment (CT), were noted in 845 and 28 patients, respectively, and inhaled iloprost, subcutaneous treprostinil, and intravenous epoprostenol were noted in 283, 30, and four patients, respectively. Bosentan was the first agent used for CT in all AdCCs and iloprost was the second. Routine use of antiaggregant, anticoagulant, and pneumococcal and influenza prophylaxis were restricted in only two AdCCs. CONCLUSION: Our nationwide data illustrate the current status of PH regarding clinical characteristics and practice patterns.

Use of tolvaptan in patients hospitalized for worsening chronic heart failure with severe hyponatremia: The initial experience at a single-center in Turkey.

OBJECTIVE: The aim of the present study was to assess the efficacy and safety of tolvaptan for severe hyponatremia (SH) in hypervolemic heart failure (HF) patients within daily clinical practice. METHODS: We restrospectively reviewed our database on tolvaptan as an add-on treatment in hypervolemic patients admitted to our clinic due to deterioration of HF and having hyponatremia resistant to standard therapy. Severe hyponatremia was defined as serum sodium concentration ≤125 mEq/L. The database included demographic, clinical, laboratory, and echocardiographic findings on admission, and numerous outcome measures for oral tolvaptan treatment were used to assess its efficacy and safety. RESULTS: The study group consisted of 56 hypervolemic HF patients with severe hyponatremia (25 female and 31 male) with mean age of 66 years. All patients received a single dose of tolvaptan 15 mg daily for an average of 3.2 days due to severe hyponatremia. Sodium and potassium concentrations, fluid intake, and urine volume increased (p<0.0001, p=0.037, p<0.0001, and p<0.0001, respectively), whereas furosemide dosage, body weight, heart rate, systolic and diastolic blood pressure, and New York Heart Association class decreased significantly in response to tolvaptan treatment, without a rise in serum creatinine or urea concentrations (p<0.0001, p<0.0001, p=0.001, p<0.049, p<0.009 ve p=0.001, respectively). CONCLUSION: In this retrospective, single-centered study conducted in a small group of Turkish patients, short-term treatment with low-dose tolvaptan added to standard therapy of hypervolemic HF patients with severe hyponatremia was well tolerated with a low rate of major side effects and was effective in correcting severe hyponatremia.

Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis.

The treatment options for high risk acute pulmonary embolism (PE) patients with failed systemic thrombolytic treatment (STT) is limited. The clinical use of catheter directed thrombolysis with the EkoSonic Endovascular System (EKOS) in this population has not been evaluated before. Catheter directed thrombolysis is an effective treatment modality for high risk PE patients with failed STT. Thirteen consecutive patients with failed STT were included in the study. EKOS catheters were placed and tissue plasminogen activator (t-PA) in combination with unfractionated heparin were given. Clinical and echocardiographic properties of the patients were collected before EKOS, at the end of EKOS and during the follow-up visit 6 months after discharge. The duration of EKOS treatment was 21.8 ± 3.8 h and the total dose of tPA was 31.2 ± 15.3 mg. One patient who presented with cardiac arrest died and the clinical status of the remaining subjects improved significantly. Any hemorrhagic complication was not observed. EKOS resulted in significant improvement of right ventricular functions and decrease of systolic pulmonary artery pressure. During a follow-up period of 6 months none of the patients died or suffered recurrent PE. In addition, echocardiographic parameters or right ventricular function significantly got better compared to in-hospital measurements. EKOS is an effective treatment modality for high risk PE patients with failed STT and can be applied with very low hemorrhagic complications.

The relationship between serum lectin-like oxidized LDL receptor-1 levels and systolic heart failure.

OBJECTIVES: Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) appears to be involved in atherosclerotic plaque vulnerability and rupture. In this study, we aimed to evaluate the utility of serum LOX-1 levels in the diagnosis and assessment of left ventricular systolic HF and LOX-1's relationship with serum pro-brain natriuretic peptide (NT-proBNP). DESIGN AND SETTINGS: This was a cross-sectional study of all eligible patients admitted to the department of cardiology of the University Hospital between July 2011 and April 2012. METHODS: Fifty-five patients with a diagnosis of systolic heart failure and 25 patients without systolic HF were enrolled in this study. Serum C-reactive protein, NT-proBNP, and LOX-1 were studied. RESULTS: Serum LOX-1 and NT-proBNP levels were significantly higher in the heart failure group and showed a positive correlation with NT-proBNP and negative correlations with left ventricular ejection fraction (EF). In addition, LOX-1 levels in patients with ischaemic cardiomyopathy were significantly higher, while they were similar in patients with dilated cardiomyopathy compared to control subjects. CONCLUSION: Our study demonstrates the utility of the serum LOX-1 levels in the diagnosis of left ventricular systolic heart failure. LOX-1 may have a place in the diagnosis of heart failure, in particular in patients with ischaemic cardiomyopathy.

Early atherosclerosis in normotensive patients with autosomal dominant polycystic kidney disease: the relation between epicardial adipose tissue thickness and carotid intima-media thickness.

Epicardial adipose tissue thickness (EATT) is suggested as a novel marker of subclinical atherosclerosis. Despite increased carotid intima-media thickness (CIMT) in autosomal dominant polycystic kidney disease (ADPKD) patients, the extent of the relationship between CIMT and EATT is unknown. The main purpose of our study was to evaluate the relation between EATT and CIMT in normotensive ADPKD patients with well-preserved renal function. Fifty-five normotensive ADPKD patients with normal renal function and 50 healthy control subjects were included in the study. EATT and CIMT were measured by echocardiography in all subjects. Correlation between EATT and CIMT was evaluated in ADPKD patients, while multivariate linear regression analysis was performed to determine factors predicting EATT and CIMT. ADPKD patients had significantly higher levels CIMT [0.7 (0.4-1.2) vs. 0.5 (0.4-0.8) mm, p < 0.001] and EATT (6.8 ± 2.7 vs. 4.8 ± 1.2 mm, p < 0.001) as compared with control subjects. Significant positive correlation was found between EATT and CIMT (r = 0.58, p < 0.001). Higher CRP levels (OR 54.7, 95 % CI 37.44-72.01, p < 0.001) and having ADPKD (OR 10.2, 95 % CI 2.53-17.86, p = 0.01) were the only independent factors associated with a higher EATT. A higher age (OR 0.35, 95 % CI -0.02 to 0.71, p = 0.06) tended to be independently associated with a higher EATT. In conclusion, our findings suggest that EATT, being simply measured by echocardiography and correlated with CIMT, can be used to detect subclinical atherosclerosis in normotensive ADPKD patients.

Correlation between arterial stiffness and inflammatory markers in autosomal dominant polycystic kidney disease patients with preserved renal function.

AIM: To evaluate the association between arterial stiffness and inflammatory markers including C-reactive protein (CRP), pentraxin 3 (PTX3) and neutrophil-to-lymphocyte ratio (NLR) in autosomal dominant polycystic kidney disease (ADPKD) patients with preserved renal function. METHODS: A total of 52 ADPKD patients [mean (SD) age 38.2 (12.8) years, 69.2 % were females] with preserved renal function and 25 healthy volunteers [mean (SD) age 35.5 (6.5) years, 48.0 % were females] were included. Data on patient characteristics, blood biochemistry, inflammatory markers [PTX3 (pg/mL), CRP (mg/dL) and NLR] and arterial stiffness [large artery elasticity index (LAEI) (mL/mmHg × 10) and small artery elasticity index (SAEI) (mL/mmHg × 100)] were recorded in patient and control groups. Correlation between inflammatory markers and arterial stiffness parameters was analysed in patients. RESULTS: Overall, 42.3 % of ADPKD patients were hypertensive and 44.4 % were receiving renin-angiotensin-aldosterone system (RAAS) blockade therapy. Median levels for PTX3 [442.0 (20.0-4140.0) pg/mL vs. 220.5 (14.7-393.0) pg/mL, p < 0.001] and SAEI [4.90 (1.60-11.80) mL/mmHg × 100 vs. 6.45 (2.80-15.70) mL/mmHg × 10, p = 0.013] were significantly higher in ADPKD patients than in controls. PTX3 and CRP were not correlated with arterial elasticity, while NLR was significantly correlated with LAEI negatively (Rho = -0.278, p = 0.042). CONCLUSION: In conclusion, our findings revealed increased PTX3 levels and reduced SAEI in patients as compared with controls, while no correlation between inflammatory markers studied and the small artery elasticity.

Myocardial performance is impaired in patients with branch retinal vein occlusion.

OBJECTIVE: To investigate whether the Tei index, which is an indicator of global myocardial function and an independent predictor of cardiac death, is increased in patients with branch retinal vein occlusion (BRVO). METHODS: The Tei index was used to evaluate myocardial performance, in addition to conventional echocardiographic evaluation of myocardial structural and functional changes, in patients with BRVO, patients with hypertension and healthy controls. RESULTS: Out of 36 patients with BRVO (18 female, 18 male; 17 hypertensive, 19 normotensive), 29 patients with hypertension (15 female, 14 male) and 28 healthy controls (15 female, 13 male), there were no significant between-group differences in age and sex. The mitral A wave was higher and mitral E/A ratio, mitral E wave and ejection time were lower, in patients with BRVO than in healthy controls. Mean Tei index was significantly higher in the BRVO group than in patients with hypertension or healthy controls. Compared with healthy controls, the Tei index was significantly higher in hypertensive and normotensive patients with BRVO. CONCLUSION: Myocardial performance is decreased in patients with BRVO, independent of whether or not they have hypertension.

[Management of multivalvular heart disease]. / Çoklu kalp kapak hastaliklarinda yönetim.

Multivalvular heart valve disease is not an uncommon situation. Although many studies include only patients with regurgitation or stenosis involving only one heart valve, several scenarios in which patients present with regurgitation and/or stenosis involving two or more valves exist. Data on multivalve disease are scarce because of a large number of possible combinations and also owing to difficulties of exact quantification and an overlap in surgical indications. Therefore, many fields related to multiple valve disease are not encountered in the current valvular heart disease guidelines. This article aims to explain multi valvular heart disease from etiology and background definition to surgical outcome, with special emphasis on echocardiographic assessment.

Arterial dysfunction in early autosomal dominant polycystic kidney disease independent of fibroblast growth factor 23.

INTRODUCTION: Recent studies report reduced vascular compliance and elevated levels of fibroblast growth factor 23 (FGF23) in patients with autosomal dominant polycystic kidney disease (ADPKD) and preserved kidney function. In the present study, we investigated the relationship between vascular compliance and FGF23 in patients in early phases of ADPKD. MATERIALS AND METHODS: We studied 54 ADPKD patients with preserved kidney function and 24 healthy individuals. All participants underwent noninvasive pulse wave analysis in order to determine large arterial elasticity index (LAEI) and small arterial elasticity index (SAEI) using a modified Windkessel model. Levels of FGF23 in addition to several cardiovascular risk factors were evaluated. Linear regression analyses were performed to determine independent correlates of LAEI, SAEI, and FGF23. RESULTS: In the ADPKD group, 33 patients were hypertensive and the remaining patients were normotensive. Serum FGF23 levels of both ADPKD groups were significantly higher than that in the controls. Both hypertensive and normotensive ADPKD patients had lower LAEI and SAEI levels compared to the controls. There was no significant correlation between vascular compliance parameters and FGF23 levels. Having ADPKD was independently associated with increased FGF23 levels and decreased SAEI. CONCLUSIONS: Fibroblast growth factor 23 was found substantially elevated and arterial compliance was found significantly decreased in early ADPKD patients regardless of hypertension. However, there was no significant correlation between FGF23 levels and arterial function parameters. Additional studies are required to determine possible mechanisms of these disturbances and cardiovascular effects of FGF23 in ADPKD patients.

Treatment with a combination of bosentan and sildenafil allows for successful liver transplantation in a patient with portopulmonary hypertension.

Pulmonary arterial hypertension (PAH) that occurs in the setting of cirrhosis and portal hypertension is referred to as portopulmonary hypertension (PPHTN). Liver transplantation (LTx) is curative, but the presence of moderate-to-severe PPHTN may be a contraindication for transplantation because of the elevated risk of peri- and post-transplantation morbidity and mortality. We report a successful liver transplantation in a patient with liver cirrhosis after treatment of moderate-to-severe PPHTN with a combination of the dual endothelin receptor antagonist bosentan and the specific phosphodiesterase-5 inhibitor sildenafil.

Serum fetuin-A levels in patients with systolic heart failure.

OBJECTIVE: Inflammation and dystrophic calcification have been associated with cardiovascular disease (CVD) and chronic heart failure (CHF). The aim of the present study was to investigate the potential usefulness of fetuin-A as a biomarker in CHF. METHODS: Serum fetuin-A was measured in 66 CHF patients with left ventricular function < 50% and in 31 healthy controls at baseline. Fetuin-A was evaluated as a diagnostic marker for systolic heart failure and compared with C-reactive protein (CRP) and pro-brain natriuretic peptide (pro-BNP). RESULTS: The levels of serum fetuin-A were significantly decreased in the CHF patients compared to the control group (P < 0.01). Although there were significant correlations between fetuin-A and certain parameters in patients and controls, none of these were present consistently in either group. It was found that serum fetuin-A levels could identify patients with systolic heart failure with a high degree of sensitivity and specificity. CONCLUSIONS: Serum fetuin-A is decreased in CHF patients, indicating that anti-inflammatory activity is downregulated in CHF and that calcification may be associated with CHF.

Serum choline levels in patients with stable angina and acute coronary syndromes: relation to the severity of coronary artery disease.

OBJECTIVE: We sought to investigate whether serum choline levels are increased across the spectrum of coronary artery disease (CAD) manifestations and correlate with the severity of coronary stenosis. METHODS: A total of 36 patients with acute coronary syndrome (ACS) [22 patients with non-ST-segment elevation ACS and 14 patients with ST-segment elevation acute myocardial infarction (STEMI)], 22 patients with stable angina pectoris (SAP), and 18 controls were recruited for the study. In ACS patients, serum choline levels were measured on admission, and at 24 and 48 h thereafter, using high-performance liquid chromatography. The severity of CAD was assessed using the Gensini score. RESULTS: Serum choline levels on admission were significantly higher in the entire group of patients with ACS than in controls. The highest level of choline was observed in the STEMI group, followed by the SAP, and the non-ST-segment elevation ACS groups. Serum choline levels decreased gradually in patients with STEMI over the 48-h period. Serum choline levels on admission, and at 24 or 48 h thereafter, did not correlate with the presence of CAD neither in patients with ACS (P=0.78, 0.98 and 0.98, respectively) nor in those with SAP (P=0.92). CONCLUSION: Our results suggest that serum choline levels are increased in ACS patients. However, there was no clear correlation between levels of choline and the severity and extent of CAD in this patient group.

Impaired left ventricular systolic and diastolic functions in patients with early grade pulmonary sarcoidosis.

AIMS: Cardiac sarcoidosis is symptomatic in only 5% of patients, and it is an independent predictor of mortality and carries a very poor prognosis. In our study, we aimed to assess left ventricle (LV) systolic and diastolic functions with tissue Doppler imaging (TDI) in patients with early grade pulmonary sarcoidosis. METHODS AND RESULTS: The study population included 55 patients with Grade I-II sarcoidosis (41 females, 14 males, mean age: 47.9 ± 10.1) and 22 healthy subjects. LV lateral and septal wall early myocardial peak velocity (E(m)), late myocardial peak velocity (A(m)), E(m) to A(m) ratio, myocardial relaxation time (RT(m)), myocardial systolic wave (S(m)) velocity, isovolumic acceleration (IVA), myocardial pre-contraction time (PCT(m)), contraction time (CT(m)), and the PCT(m) to CT(m) ratio were measured. No statistically significant difference was detected between the groups according to age, gender, body mass index, systolic and diastolic blood pressure, or heart rate. LV systolic parameters, LV septal, and lateral wall IVA, were significantly lower, and the PCT(m) to CT(m) ratio (P = 0.026) was higher at the septal annulus as compared with control group. E(m), a LV diastolic parameter, was significantly lower at the septal annulus. CONCLUSION: Cardiac sarcoid involvement is not rare and is treatable. It should be identified at an early stage. TDI, especially IVA, may be a suitable tool for the early detection of subclinical LV sarcoid involvement.