Lung B-lines Research Articles

Associations of different definitions of iron deficiency with cardiac structure and function, congestion, exercise capacity and prognosis in heart failure

Abstract Background It is uncertain how best to diagnose iron deficiency (ID) in patients with heart failure (HF) as different ID definitions have been proposed with discordant results. Objectives To assess the relationship of different ID definitions with cardiac structure and function, congestion, exercise capacity, and prognosis in outpatients with HF. Methods ID was defined according to guidelines (G-ID: ferritin <100 ng/mL or ferritin 100-299 ng/mL with transferrin saturation [TSAT] <20%) or as TSAT <20%. Alternative definitions (iron <13 ¼mol/L, ferritin <100 and <300 ng/mL) were explored. Relationship with rest and exercise ultrasound findings, cardiopulmonary exercise testing and a composite endpoint of cardiovascular hospitalisations or all-cause mortality were assessed. Results Of 1502 patients (72% with left ventricular ejection fraction [LVEF] ≥50%), 471 (31%) had TSAT <20%, while 728 (48%) had G-ID. Compared to those without ID, patients with TSAT <20% or G-ID showed impaired cardiac structure and function at rest and peak exercise and lower peak oxygen consumption; they were also more likely to display a discontinuous renal venous flow pattern and more lung B-lines. Only TSAT <20% was associated with significant inferior vena cava dilatation. Lower TSAT, iron and haemoglobin were associated with more severe effort intolerance and ultrasound signs of congestion, while ferritin and LVEF were not (Picture 1). During a median follow-up of 16 months, 62 (4%) patients died, and 244 (16%) were hospitalised for cardiovascular reasons. No patients were hospitalised immediately after the enrolment visit because of clinical findings. At Kaplan-Meier analyses, TSAT <20% was associated with a greater risk of adverse events, as were iron ≤13 ¼mol/L, ferritin ≥300 ng/mL and <100 ng/mL (p <0.01 vs ferritin 100-299 ng/mL) and G-ID (Picture 2). After adjusting for age, sex, diabetes, haemoglobin, estimated glomerular filtration rate (eGFR), NT-proBNP, rest LVEF and peak VO2 <16 mL/kg/min, TSAT <20% and iron ≤13 ¼mol/L were associated with worse outcomes (hazard ratio 2.41, 95% confidence interval 1.85-3.14 and 1.90, 1.46-2.47), while G-ID or ferritin <100 or <300 ng/mL were not (Picture 1). Conclusions In outpatients with HF, TSAT <20% is more consistently associated with echocardiographic signs of poorer functional capacity and multi-organ congestion than other ID definitions. TSAT <20% and iron ≤13 ¼mol/L, but not G-ID or ferritin-based ID, seem to predict a worse prognosis.Picture 1Picture 2

Usefulness of Antigen Carbohydrate 125 and N-Terminal Pro-B-Type Natriuretic Peptide for Assessing Congestion in Chronic Heart Failure: Insights from the CARDIOREN Registry

Introduction: A comprehensive assessment of congestion, including circulating biomarkers, is recommended in patients with acute heart failure. The circulating biomarkers natriuretic peptides (NPs) and carbohydrate antigen-125 (CA125) could be useful for congestion assessment in ambulatory chronic heart failure (CHF), but there is only limited information about their applicability in this context. Therefore, this study aimed to examine the association of plasma CA125 and NP levels with clinical and ultrasound congestion parameters in CHF. Methods: This is a cross-sectional substudy of the Cardioren Spanish Registry, which enrolled 1,107 patients with CHF from 13 tertiary hospitals in Spain between October 2021 and February 2022. Through ambulatory visits, we performed a comprehensive assessment of congestion-related parameters, including clinical variables (orthopnea, peripheral edema, and jugular engorgement, represented by the composite congestion score [CCS]), echocardiography variables (lung B-lines and inferior vena cava [IVC] diameter), and circulating biomarkers (CA125 and NPs). The association of the NP and CA125 levels with the clinical and echocardiographic congestion parameters was examined by multiple linear and logistic regression analyses. Results: This substudy included 802 patients for whom all the biomarker parameters were available {median age, 74 (interquartile range [IQR], 63–81) years; 65% male}. The proportion of patients with left ventricular ejection fraction ≥50% and estimated glomerular filtration rate <60 was 34% and 58%, respectively. The median CCS was 0 (IQR: 0–1), with 45% of the sample exhibiting a median CCS of ≥1. The jugular engorgement, peripheral edema, and orthopnea rates were 32%, 21%, and 21%, respectively. A total of 35% of patients who underwent ultrasound examination showed lung B-lines, and the median IVC diameter was 16 mm. The median CA125 and NTproBNP levels were 14 U/mL (IQR: 9–28) and 1,382 pg/mL (IQR: 563–3,219), respectively. Multivariate analysis showed that higher CA125 levels were independently associated with higher odds of peripheral edema (p = 0.023) and lung B-lines (p < 0.001). Further, NTproBNP was positively associated with jugular engorgement (p < 0.001), orthopnea (p = 0.034), and enlarged IVC diameter (p = 0.031). Conclusions: Clinical signs of congestion are frequent in CHF. In the ambulatory setting, NTproBNP was associated with parameters linked to intravascular congestion such as orthopnea, jugular engorgement, and IVC diameter, whereas CA125 was associated with extravascular volume overload parameters (peripheral edema and lung B-lines).

Cardiovascular effects of breath-hold diving at altitude

ABSTRACT Marabotti C, Laurino M, Passera M, Cialoni D, Franzino E, Benvenuti C, Pingitore A. Cardiovascular effects of breath-hold diving at altitude. Undersea Hyperb Med. 2024 Second Quarter; 51(2):189- 196. Hypoxia, centralization of blood in pulmonary vessels, and increased cardiac output during physical exertion are the pathogenetic pathways of acute pulmonary edema observed during exposure to extraordinary environments. This study aimed to evaluate the effects of breath-hold diving at altitude, which exposes simultaneously to several of the stimuli mentioned above. To this aim, 11 healthy male experienced divers (age 18-52y) were evaluated (by Doppler echocardiography, lung echography to evaluate ultrasound lung B-lines (BL), hemoglobin saturation, arterial blood pressure, fractional NO (Nitrous Oxide) exhalation in basal condition (altitude 300m asl), at altitude (2507m asl) and after breath-hold diving at altitude. A significant increase in E/e’ ratio (a Doppler-echocardiographic index of left atrial pressure) was observed at altitude, with no further change after the diving session. The number of BL significantly increased after diving at altitude as compared to basal conditions. Finally, fractional exhaled nitrous oxide was significantly reduced by altitude; no further change was observed after diving. Our results suggest that exposure to hypoxia may increase left ventricular filling pressure and, in turn, pulmonary capillary pressure. Breath-hold diving at altitude may contribute to interstitial edema (as evaluated by BL score), possibly because of physical efforts made during a diving session. The reduction of exhaled nitrous oxide at altitude confirms previous reports of nitrous oxide reduction after repeated exposure to hypoxic stimuli. This finding should be further investigated since reduced nitrous oxide production in hypoxic conditions has been reported in subjects prone to high-altitude pulmonary edema.

Assessment of volume status of pediatric hemodialysis patients.

Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. A total 60 children (mean age 9.4 ± 2.8years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients.

Right heart failure as a source of B-lines at lung ultrasound: prevalence and functional correlates

Abstract Background Lung ultrasound is part of the standard transthoracic examination and B-lines provide an index of extravascular lung water allowing to measure pulmonary congestion in left heart failure. However, pulmonary congestion can also appear as a consequence of right heart failure and it has been assumed that depends on the increase in central venous pressure increasing the resistance to lymphatic drainage. Aim of this study was to assess the prevalence of lung B-lines in a clinical model of pure right heart failure due to idiopathic pulmonary arterial hypertension (PAH) and its correlation with haemodynamic parameters. Methods All patients referred for suspicion of pulmonary hypertension in a single tertiary centre from January 2020 to December 2022 underwent a complete diagnostic work-up including echocardiography, lung ultrasound and right heart catheterization. The diagnosis of PAH was made following the current international recommendations. Pulmonary congestion was identified by lung ultrasound B-lines using an 8-site scan. Results The study enrolled 102 patients with PAH. Patients’ characteristics are shown in Table 1. The median lung B-lines were 3 [IQR: 1-5]. Results of univariate and multivariate analysis of B-lines predictors are shown in Table 1. Right atrial pressure (RAP), tricuspid annular plane excursion (TAPSE)/ Systolic pulmonary pressure (sPAP) ratio and pro hormone brain natriuretic peptide (proBNP) were independent predictors of B lines. Conclusion RAP, TAPSE/sPAP and proBNP were independent predictors of B lines in PAH patients according to the pathophysiological hypothesis that B-lines depends on the increase in central venous pressure increasing the resistance to lymphatic drainage.Table 1

Multi-organ sonographic assessment of congestion has incremental prognostic value in outpatients with heart failure irrespective of left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Congestion is a key driver of symptoms, disease progression and prognosis for patients with heart failure (HF), irrespective of left ventricular ejection fraction (LVEF). However, clinically overt congestion is often undiagnosed unless severe. Recent research has shown that ultrasonographic quantification of systemic venous (i.e. inferior vena cava), renal venous and lung (B-lines) congestion is feasible and identifies HF patients with a worse prognosis. Purpose Whether a simultaneous multi-organ evaluation of congestion by ultrasound may improve risk stratification in HF is unknown. In the present study, we assessed signs of ultrasonographic congestion in the inferior vena cava, lungs and kidneys in HF patients across the LVEF spectrum and investigated their association with pathophysiology, clinical characteristics and prognosis. Methods We prospectively enrolled 326 patients with a prior clinical diagnosis of HF attending a routine follow-up visit. We also enrolled 102 consecutive patients with cardiovascular risk factors (including hypertension, type II diabetes mellitus or chronic ischaemic heart disease) and no history of HF; these latter patients had NT-proBNP levels &amp;lt;125 ng/L, LVEF &amp;gt;50%, and were not taking loop diuretics. All patients underwent a complete clinical assessment, blood and urine tests, and an ultrasound evaluation. Ultrasound congestion was defined as inferior vena cava ≥21 mm, highest tertile of lung B-lines or discontinuous renal venous flow. Results The final population consisted of 310 HF patients (median age 77 years, median NT-proBNP 1037 ng/L, 51% with LVEF &amp;lt;50%), and 101 subjects without HF. Among the 224 HF patients (72%) with no clinical signs of congestion, 95 (42%) had at least one sign of congestion by ultrasound (p&amp;lt;0.0001). HF patients with ≥2 ultrasound signs were older, had greater neurohormonal activation (i.e., higher NT-proBNP; Figure 1), lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range 6–15) months, 77 HF patients (19%) died or were hospitalized for HF. HF patients without ultrasonographic evidence of congestion had a similar outcome to subjects without HF (reference; HR 1.02, 95% CI 0.86 – 1.35), while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4–63.6), even after adjusting for multiple clinical variables and NT-proBNP (Figure 2). Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a 28% net reclassification improvement (p=0.03). Conclusion Simultaneous assessment of pulmonary, systemic venous and kidney congestion by ultrasound identifies a high prevalence of sub-clinical congestion associated with poor outcomes in HF, irrespective of LVEF. The speed of investigation, along with the widespread availability and relatively low cost of ultrasound, makes this protocol easy to implement for real-time assessment of congestion.

Assessment of fluid removal using ultrasound, bioimpedance and anthropometry in pediatric dialysis: a pilot study

BackgroundFluid overload is associated with morbidity and mortality in children receiving dialysis. Accurate clinical assessment is difficult, and using deuterium oxide (D2O) to measure total body water (TBW) is impractical. We investigated the use of ultrasound (US), bioimpedance spectroscopy (BIS), and anthropometry to assess fluid removal in children receiving maintenance hemodialysis (HD).MethodsParticipants completed US, BIS, and anthropometry immediately before and 1–2 h after HD for up to five sessions. US measured inferior vena cava (IVC) diameter, lung B-lines, muscle elastography, and dermal thickness. BIS measured the volume of extracellular (ECF) and intracellular (ICF) fluid. Anthropometry included mid-upper arm, calf and ankle circumferences, and triceps skinfold thickness. D2O was performed once pre-HD. We assessed the change in study measures pre- versus post-HD, and the correlation of change in study measures with percent change in body weight (%∆BW). We also assessed the agreement between TBW measured by BIS and D2O.ResultsEight participants aged 3.4–18.5 years were enrolled. Comparison of pre- and post-HD measures showed significant decrease in IVC diameters, lung B-lines, dermal thickness, BIS %ECF, mid-upper arm circumference, ankle, and calf circumference. Repeated measures correlation showed significant relationships between %∆BW and changes in BIS ECF (rrm =0.51, 95% CI 0.04, 0.80) and calf circumference (rrm=0.80, 95% CI 0.51, 0.92). BIS TBW correlated with D2O TBW but overestimated TBW by 2.2 L (95% LOA, -4.75 to 0.42).ConclusionBIS and calf circumference may be helpful to assess changes in fluid status in children receiving maintenance HD. IVC diameter, lung B-lines and dermal thickness are potential candidates for future studies.

The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure.

We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients. Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03). Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.

C25. Cardiogenic shock in a 25-year-old male with tombstone ST-segment elevation pattern in emergency department, early hemodynamic assessment to guide the management: a case report of mixed cardiogenic shock phenotype

Abstract Background Cardiogenic shock (CS) is a lethal condition. There are several phenotypes, and classification based hemodynamic and/or clinical parameters for CS. We present CS with tombstone ST-segment elevation in emergency department (ED) with assessment of hemodynamic using bedside ultrasound to classify and guide the management. Case Description A 25-year-old-male complained sense of fatigue, fever, and myalgia for 2 days. The initial blood pressure and SpO2 were unrecordable, heart rate 112x/m, respiration rate 28x/m, temperature 36.8 °C. The patient was pale, anxious, with difficult jugular venous pressure assessment due to overweight appearance, diminished S1, and cold extremity. Electrocardiogram revealed tombstone ST-elevation in V2-V6, I, and aVL. After oxygenation management, initial dobutamine and norepinephrine, we performed bedside cardiac ultrasound revealed anterior left ventricular wall hypokinesis, mild pericardial effusion, ejection fraction 52%, mitral E/A ratio 2.7, E deceleration time 90.82ms, positive lung B-lines, inferior vena cava diameter 2.14cm with collapsibility &amp;lt;50%. Tricuspid annular plane systolic excursion 19mm. Estimated cardiac index 1.88L/m/cm2, and systemic vascular resistance (SVR) 775dynes.sec/cm5. This pattern suggests mixed CS phenotype. Vasopressor was up titrated with improved blood pressure, SpO2, and urinary output. CXR revealed cardiomegaly, troponin T &amp;gt; 10.000pg/ml. The patient was successfully stabilized in ED and transferred to ICCU. Discussion We classify our case as mixed CS. With hemodynamic assessment, we can determine the character of the shock with more objective parameters, guide the treatment, and avoiding over (increase oxygen demand, afterload, arrhythmia) and underused of vasopressor to bridging the treatment of causative factor.

C25. Cardiogenic shock in a 25-year-old male with tombstone ST-segment elevation pattern in emergency department, early hemodynamic assessment to guide the management: a case report of mixed cardiogenic shock phenotype

Abstract Background Cardiogenic shock (CS) is a lethal condition. There are several phenotypes, and classification based hemodynamic and/or clinical parameters for CS. We present CS with tombstone ST-segment elevation in emergency department (ED) with assessment of hemodynamic using bedside ultrasound to classify and guide the management. Case Description A 25-year-old-male complained sense of fatigue, fever, and myalgia for 2 days. The initial blood pressure and SpO2 were unrecordable, heart rate 112x/m, respiration rate 28x/m, temperature 36.8 °C. The patient was pale, anxious, with difficult jugular venous pressure assessment due to overweight appearance, diminished S1, and cold extremity. Electrocardiogram revealed tombstone ST-elevation in V2-V6, I, and aVL. After oxygenation management, initial dobutamine and norepinephrine, we performed bedside cardiac ultrasound revealed anterior left ventricular wall hypokinesis, mild pericardial effusion, ejection fraction 52%, mitral E/A ratio 2.7, E deceleration time 90.82ms, positive lung B-lines, inferior vena cava diameter 2.14cm with collapsibility &amp;lt;50%. Tricuspid annular plane systolic excursion 19mm. Estimated cardiac index 1.88L/m/cm2, and systemic vascular resistance (SVR) 775dynes.sec/cm5. This pattern suggests mixed CS phenotype. Vasopressor was up titrated with improved blood pressure, SpO2, and urinary output. CXR revealed cardiomegaly, troponin T &amp;gt; 10.000pg/ml. The patient was successfully stabilized in ED and transferred to ICCU. Discussion We classify our case as mixed CS. With hemodynamic assessment, we can determine the character of the shock with more objective parameters, guide the treatment, and avoiding over (increase oxygen demand, afterload, arrhythmia) and underused of vasopressor to bridging the treatment of causative factor.

Association Between Arterial Oxygen Saturation and Lung Ultrasound B-Lines After Competitive Deep Breath-Hold Diving.

Breath-hold diving (freediving) is an underwater sport that is associated with elevated hydrostatic pressure, which has a compressive effect on the lungs that can lead to the development of pulmonary edema. Pulmonary edema reduces oxygen uptake and thereby the recovery from the hypoxia developed during freediving, and increases the risk of hypoxic syncope. We aimed to examine the efficacy of SpO2, via pulse-oximetry, as a tool to detect pulmonary edema by comparing it to lung ultrasound B-line measurements after deep diving. SpO2 and B-lines were collected in 40 freedivers participating in an international deep freediving competition. SpO2 was measured within 17 ± 6 min and lung B-lines using ultrasound within 44 ± 15 min after surfacing. A specific symptoms questionnaire was used during SpO2 measurements. We found a negative correlation between B-line score and minimum SpO2 (rs = −0.491; p = 0.002) and mean SpO2 (rs = −0.335; p = 0.046). B-line scores were positively correlated with depth (rs = 0.408; p = 0.013), confirming that extra-vascular lung water is increased with deeper dives. Compared to dives that were asymptomatic, symptomatic dives had a 27% greater B-line score, and both a lower mean and minimum SpO2 (all p < 0.05). Indeed, a minimum SpO2 ≤ 95% after a deep dive has a positive predictive value of 29% and a negative predictive value of 100% regarding symptoms. We concluded that elevated B-line scores are associated with reduced SpO2 after dives, suggesting that SpO2 via pulse oximetry could be a useful screening tool to detect increased extra-vascular lung water. The practical application is not to diagnose pulmonary edema based on SpO2 – as pulse oximetry is inexact – rather, to utilize it as a tool to determine which divers require further evaluation before returning to deep freediving.

Use of Point-of-Care Ultrasound for Evaluation of Extravascular and Intravascular Fluid Status in Pediatric Patients Maintained on Chronic Hemodialysis

Aims: Traditional methods that use clinical parameters to determine dry weight in hemodialysis patients are inaccurate. This study aimed to compare clinical assessment of fluid status to sonographic parameters of fluid status in pediatric patients undergoing chronic hemodialysis. Methods: In a prospective observational study, pediatric patients maintained on chronic hemodialysis (ages 2.3–20 years) were evaluated clinically and sonographically before and after dialysis at 6 consecutive sessions. Sonographic parameters examined were number of lung B-lines as a measure of extravascular volume and inferior vena cava (IVC)/aorta ratio as a measure of intravascular volume. Clinical assessment of fluid status was compared to sonographic assessment. Results: Twelve patients were evaluated during 72 dialysis sessions. Sonographic parameters were significantly lower post-dialysis than pre-dialysis (B-lines number 4.5 ± 5 vs. 7.69 ± 7.46, p < 0.0001; IVC/aorta ratio 0.9 ± 0.2 vs. 1.1 ± 0.2, p < 0.0001, respectively). Ultrafiltration volume correlated with change in B-lines number during dialysis (r = 0.39, p < 0.01). Percent of blood volume drop correlated with post-dialysis IVC/aorta ratio (r = 0.48, p < 0.001). A higher percent of symptomatic episodes occurred with post-dialysis IVC/aorta ratio <0.8 versus ≥0.8 (39.1 vs. 15.2%, p = 0.036). Four patients were hypertensive, a clinical parameter implying fluid overload, in only one sonographic evaluation indicated fluid overload. Eight patients were clinically determined to be euvolemic, in three of them sonographic evaluation discovered covert fluids. Conclusion: Bedside ultrasound is a single modality that can be used to assess both extravascular and intravascular fluid status. It may contribute to clinical decisions differentiating fluid-related versus fluid-unrelated hypertension and identifying patients with covert fluids.

Lung Ultrasound Surface Wave Elastography for Assessing Patients With Pulmonary Edema.

B-Mode ultrasound insonation of lungs that are dense with extravascular lung water (EVLW) produces characteristic reverberation artifacts termed B-lines. The number of B-lines present demonstrates reasonable correlation to the amount of EVLW. However, analysis of B-line artifacts generated by this modality is semi-quantitative relying on visual interpretation, and as a result, can be subject to inter-observer variability. The purpose of this study was to translate the use of a novel, quantitative lung ultrasound surface wave elastography technique (LUSWE) into the bedside assessment of pulmonary edema in patients admitted with acute congestive heart failure. B-mode lung ultrasound and LUSWE assessment of the lungs were performed using anterior and lateral intercostal spaces in the supine patient. 14 patients were evaluated at admission with reassessment performed 1-2 days after initiation of diuretic therapy. Each exam recorded the total lung B-lines, lung surface wave speeds (at 100, 150, and 200 Hz) and net fluid balance. The patient cohort experienced effective diuresis (average net fluid balance of negative 2.1 liters) with corresponding decrease in pulmonary edema visualized by B-mode ultrasound (average decrease of 13 B-Lines). In addition, LUSWE demonstrated a statistically significant reduction in the magnitude of wave speed from admission to follow-up. The reduction in lung surface wave speed suggests a decrease in lung stiffness (decreased elasticity) mediated by successful reduction of pulmonary edema. In summary, LUSWE is a noninvasive technique for quantifying elastic properties of superficial lung tissue that may prove useful as a diagnostic test, performed at the bedside, for the quantitative assessment of pulmonary edema.

Association between lung comets and subendocardial viability ratio in peritoneal dialysis patients.

Pulmonary congestion is a direct result of either general overhydration or cardiac dysfunction. Lung ultrasonography (LUS) with lung B-lines (LUS comets) can be used to assess extravascular lung water in patients with end-stage renal disease on hemodialysis or peritoneal dialysis (PD). Subendocardial viability ratio (SEVR) is a pulse wave analysis parameter that is a non-invasive measure of coronary perfusion and is related to cardiac work and oxygen consumption. Our aim was to investigate the association between LUS comets and SEVR in PD patients. We performed an observational study in 25 PD patients in a single dialysis center. Extravascular lung water was quantified by the number of LUS comets, using a portable ultrasound (US) device. LUS comets were recorded in each intercostal space and defined as hyperechoic US bundles at a narrow base extending from the transducer to the edge of the screen. The sum of LUS comets yields a score reflecting the extent of water accumulation in the lungs. SEVR was determined non-invasively by radial applanation tonometry. Mean age of patients was 54.7 ± 10.7 years, mean PD vintage 27 ± 33 (1 - 167) months, 60% were men. The mean number of LUS comets was 13 ± 19 (0 - 71), and the mean SEVR was 153 ± 40%. We found a statistically significant negative correlation between the number of LUS comets and SEVR (r = -0.467; p = 0.019). Multiple regression analysis with LUS comets as dependent variable, and SEVR and age as independent variables showed a statistically significant relationship between SEVR and the number of LUS comets (β = -0.467, p = 0.021). Higher number of LUS comets is associated with lower SEVR in PD patients.

P1185LUNG COMETS AND EVALUATION OF HYDRATION STATUS IN PERITONEAL DIALYSIS PATIENTS

Abstract Background and Aims Assessment of optimal hydration status in patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD) is a challenge. Multiple diagnostic options to determine hydration status in PD patients are available. Multifrequency bioimpedance spectroscopy (MBIS) is a cheap, simple and non-invasive method of estimating body composition, including estimates of total body water (TBW), extracellular water (ECW), intracellular water (ICW) and the ratio between both spaces (ECW/ICW). Lung ultrasonography (LUS) and lung B-lines (lung comets) can be used for the evaluation of extravascular lung water. Ultrasound evaluation of inferior vena cava (UIVC) provides rapid, non-invasive assessment of a patient's hemodynamic and volume status. N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to fluid status and fluid distribution. The aim of our study was to assess fluid status in PD patients comparing four different methods: MBIS, LUS, UIVC and NT-proBNP. Method We performed a single-centre cohort study in 19 PD patients. The body composition was measured using the portable whole-body MBIS device, Body Composition Monitor-BCM(®) (Fresenius Medical Care, Bad Homburg, Germany), LUS with portable US device (VScan, General Electrics Corporate), UIVC index with SonoSite US device. NT-proBNP was measured in a one-step sandwich chemiluminescent immunoassay (Dimension Vista® System 1500, Siemens Healthcare Diagnostics Inc., Newark, NJ, USA). Results The mean age of patients was 54 ± 10 years, mean dialysis vintage 53 (10-194) months, 63% were men. Thirteen (68.4%) patients had fluid overload (FO) &amp;gt; 1.1 L. Data of patients are presented in table 1. We found a statistically significant correlation between the number of lung comets and ECW/ICW ratio (r = 0.496, P = 0.031) and NT-proBNP (r = 0.759, P &amp;lt; 0.0001). In contrast, there was no significant correlation between the number of lung comets and UIVC (r = 0.221, P &amp;lt; 0.364). Conclusion According to our results, LUS with lung comets, MBIS with ECW/ICW ratio and NT-proBNP are useful and complementary methods for evaluation of fluid status in PD patients.

Ultrasound indices of congestion in patients with acute heart failure according to body mass index.

The inverse relationship between body mass index (BMI) and natriuretic peptide levels complicates the diagnosis of heart failure (HF) in obese patients. Assessment of congestion with ultrasound could facilitate HF diagnosis but it is unclear if any relationship exists amongst BMI, inferior vena cava (IVC) diameter and the number of B-lines. We performed a comprehensive echocardiographic evaluation within 24h from hospital admission in patients with HF, including lung B-lines and IVC diameter, and studied their relationship with BMI and outcome. 216 patients (median age 81 (77-86) years) were enrolled. Median number of B-lines was 31 (IQR 26-38), median IVC diameter was 23 (22-25) mm and median BNP 991 (727-1601) pg/mL. BMI was inversely correlated with B-lines (r = - 0.50, p < 0.001), but not with IVC diameter (r = - 0.04, p = 0.58). Compared to overweight patients (BMI 25-29.9 kg/m2; n = 100) or with a normal BMI (BMI < 25 kg/m2; n = 59), obese patients (BMI ≥ 30 kg/m2; n = 57) had lower B-lines [28 (24-33) vs 30 (26-35), and vs 38 (32-42), respectively; p < 0.001] but similar IVC diameter. During the first 60days of follow-up, there were 53 primary events: 29 patients died and 24 had a HF-related hospitalisation. B-lines and IVC diameter were independently associated with an increased risk. However, B-lines were less likely to predict outcome in the subgroup of patients with a BMI ≥ 30kg/m2. Assessment of IVC diameter or B-lines in patients admitted with AHF identifies those at greater risk of death or HF readmission. However, assessment of B-lines might be influenced by BMI.

The Observation on Risk of Ventilator Failure Weaning by Ultrasound bedside Monitoring of Inferior Vena Cava and Lung B Line

Objective: This study was designed to investigate risk of ventilator weaning by ultrasound bedside monitoring of the width of inferior vena cava (IVC) and the number of lung B-lines (B-lines). Methods: This study was conducted on 106 patients from January 2019 to January 2020 who had mechanical ventilation for more than 48 hours in an emergency care unit. They were clinically stable and had the criteria for weaning from the ventilator. Before Spontaneous Breathing Test (SBT) and 30 min or 120 min after SBT, the width of IVC and the number of B-lines in patients were monitored via bedside ultrasound. There were 87 cases of successful weaning as a control group and 19 cases of ventilator failure weaning as a study group. Changes of the width of IVC and the number of B-lines were compared in the different stages of SBT. Results: A total of 106 patients were included in this study. There were 87 cases of ventilator successful weaning and 19 cases failure weaning. The weaning success rate was 82.08%. The width of IVC and the number of B-lines in the study group were higher than those in the control group in same stage of SBT, the difference was statistically significant (P 0.05), and significant difference in the study group. Conclusion: The width of IVC and the number of B-lines monitored by bedside ultrasound can assess the risk of ventilator weaning, it may be caused by cardiopulmonary interaction.

P208 Abnormal coronary flow reserve assessed with stress echocardiography induces a reduction in transmural strain gradient and an increase in heterogeneous myocardial electrical activation

Abstract OnBehalf Echo Lab INC Background The integrated quadruple stress echo (IQ-SE) is a state-of-the-art protocol that expands the risk stratification potential of SE. The coronary flow reserve (CFVR) has pronostic implication mainly in the absence of wall motion abnormalities. Longitudinal multilayer strain analysis assesses trasmural strain gradient. The prognostic value of multilayer strain analysis alongside the IQ-SE has not been established. We aim to determine the additive value of multilayer strain analysis during IQ-SE. Methods Prospective observational study. We evaluated one hundred twenty intermediate-high risk patients without obstructive coronary artery disease (mean age 61 ± 12 years, female 43%) with IQ-SE dipyridamole at our institution. Abnormal CFVR was defined as CFVR &amp;lt;2. Multilayer strain analysis and mechanical dispersion, were performed during rest and stress, with an automatic frame-by-frame with speckle tracking. Results The IQ-SE was feasible in all patients. At rest, mean three-dimensional left ventricular ejection fraction (3D LVEF) was 59% (53-62) without wall motion abnormalities. Abnormal CFVR was seen in 38 patients (32%) and reduced left ventricular contractile reserve (LVCR) in 56 patients (46%). Patients with abnormal CFVR, showed a reduction in EndoLS and transmural strain gradient, and an increase in mechanical dispersion and in lung B-lines during stress. No differences were observed in 3D LVEF and LVCR. Conclusions Endocardial ischemia due to microvascular dysfunction leads to a reduction in transmural strain gradient. Adding multilayer strain analysis to IQ-SE might detect myocardial subclinical dysfunction, arrhythmic risk and pulmonary congestion due to microvascular dysfunction. Left ventricular mechanics analysis CVFR &amp;lt;2 (38) CVFR &amp;gt;2 (81) P Rest EpiLS (%) -14.9 ±4.2 -18 ± 3.7 0.001 EndoLS (%) -20.2 ± 5.9 -23.5 ± 4.5 0.001 EndoLS- EpiLS 5.1 (3.8-6.3) 5.4 (4.2-6.3) 0.27 Mechanical Dispersion (ms) 57.7 (42.2-69) 44.2 (35-54) 0.006 Stress EpiLS (%) -17.2 ± 4.8 -20 ± 4.4 0.003 EndoLS (%) -23 ± 6 -26.6 ± 5.7 0.002 EndoLS- EpiLS 5.6 (4.5-6.7) 6.3 (5.4-7.9) 0.01 Mechanical Dispersion (ms) 47 (39.5 - 59) 39 (30-54.6) 0.007 CVFR: coronary flow reserve; EpiLS: Epicardium longitudinal strain; EndoLS: endocardial longitudinal strain; EndoLS- EpiLS: trasmural strain gradient. Abstract P208 Figure. IQ-SE and Multilayer Strain

P659 Patterns of diastolic dysfunction and correlation with lung ultrasound B-lines among patients with end-stage renal disease

Abstract Background Cardiovascular disease is the leading cause of death among patients with end-stage renal disease (ESRD). The degree of diastolic dysfunction (DD) as assessed by the E/e’ ratio correlates with worsening eGFR and the presence of diastolic dysfunction is an independent predictor of mortality for these patients. Purpose This study aimed to evaluate the patterns of DD in patients with end-stage renal disease not on renal replacement therapy (RRT) and investigate the correlation with lung ultrasound B-lines as an indicator of the hydration status. Methods Population: CKD patients with eGFR &amp;lt;15 ml/min/1.73 m2 referred for echocardiography. According to the ESC recommendations for DD assessment, the following parameters derived from conventional 2D echocardiography, tissue and conventional doppler imaging were used: average E/e’, septal and lateral e’ velocities, tricuspid regurgitation (TR) velocity, left atrial volume index (LAVi), E/A, E wave velocity, EF. Lung B-lines were assessed at the same time by scanning 28 intercostal spaces (IS) on the antero-lateral chest, 2nd-5thIS along with the midaxillary, anterior axillary, midclavicular and parasternal lines. In each IS, the B-lines were counted from 0 = black lung to 10 = white lung. Results 60 patients (41 males) with an eGFR &amp;lt; 15 ml/min/1.73 m2(CKD-EPI) were included (mean eGFR = 8.3 ml/min/1.73 m2). The mean age was 61 (range 19-83) years old and 28.9% were diabetic. The number of B-lines varied between 0 and 80, with a median of 21. Of the 60 patients enrolled, 19 patients (31.6%) had an EF of &amp;lt;50%. All of them had at least grade I DD and an increased LAVi. 41 patients (68.3%) had a preserved EF (pEF) and among these, 33 had diastolic dysfunction (80.4%). Overall, 52 of the 60 patients enrolled (86.6%) had DD (54.5 % grade I, 42.4 % grade II, 3 % grade III). Mean E/e’, lateral and septal e’, LAVi, TR velocity and the grade of DD were independently correlated with the number of B-lines - as assessed by lung ultrasound (p = 0.03, r = 0.34; p = 0.005, r = 0.43; p = 0.01, r = 0.40; p = 0.04, r = 0.32; p = 0.04; r = 0.32 and p = 0.02; r = 0.37 respectively). Additionally, the number of B-lines correlated with eGFR (p = 0.0008; r = 0.51), hemoglobin (Hb) levels (p = 0.03: r = 0.33) and EF (p = 0.0002; r = 0.56). In multiple regression analysis of a model consisting of E/e’, eGFR, Hb and B-lines, the number of B-lines counted for 18% of the variance of E/e’ (R2= .118, p = 0.03, F = 4.833). Conclusions Our study confirms that DD is extremely common among patients with ESRD even in the presence of a pEF. Additionally, we proved for the first time the independent correlation between the number of B-lines as assessed by lung ultrasound and the grade of DD in ESRD patients not yet on RRT. As it correlates with worse prognosis and mortality, further studies are needed to determine whether improving DD in patients with ESRD translates into better outcomes.

Prognostic Implications of a Point-of-Care Ultrasound Examination on Hospital Ward Admission.

Few data exist regarding the use of ultrasound (US) to risk stratify ward admissions. Therefore, we evaluated associations between a cardiopulmonary limited ultrasound examination (CLUE) on admission and subsequent hospital outcomes. Over a 22-month period in a 300-bed hospital, CLUE data reviewed from a series of nonelective ward admissions were correlated with the composite outcome of a hospital stay of longer than 2 days, disposition to hospice, or death. The CLUE included 5 quick-look signs of left ventricular dysfunction, left atrial enlargement, lung B-lines, pleural effusions, and inferior vena cava plethora and had been performed as warranted by 1 of 31 US-trained admitting residents and then repeated by a cardiologist as the reference standard. The admitting condition, medical history, results of routine admission testing, and CLUE were assessed for an association with the outcome in univariate and multivariable models. Of 547 patients, the mean age ± SD was 62.9 ± 15.5 years; 59% were male; and the mean stay was 5.6 ± 8.1 days, with 355 (65%) lasting longer than 2 days and 21 (4%) having hospice disposition or death. An abnormal CLUE exam was found in 368 (67%) of patients, was related to the outcome (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.23-2.68; P = .001) when obtained by a resident or cardiologist, and was included in a best-fit multivariable model with renal failure (OR, 2.44; 95% CI, 1.44-4.14; P < .001), infection/sepsis (OR, 2.25; 95% CI, 1.17-4.32; P = .02), and chest pain (OR, 0.36; 95% CI, 0.21-0.61; P < .001). An abnormal admission point of care ultrasound exam was related to complex hospitalization, specifically a longer length of stay.