Number Of B-lines Research Articles

Integrated Assessment of Heart, Lung and Lower Extremity Veins Using Hand-Held Ultrasound Device in COVID-19 Patients: Feasibility and Clinical Application

The emergence of the COVID-19 pandemic caused a significant shortage of medical personnel and the prioritization of life-saving procedures on internal medicine and cardiology wards. Thus, the cost- and time-effectiveness of each procedure proved vital. Implementing elements of imaging diagnostics into the physical examination of COVID-19 patients could prove beneficial to the treatment process, providing important clinical data at the moment of admission. Sixty-three patients with positive COVID-19 test results were enrolled into our study and underwent physical examination expanded with a handheld ultrasound device (HUD)-performed bedside assessment included: right ventricle measurement, visual and automated LVEF assessment, four-point compression ultrasound test (CUS) of lower extremities and lung ultrasound. Routine testing consisting of computed-tomography chest scanning, CT-pulmonary angiogram and full echocardiography performed on a high-end stationary device was completed in the following 24 h. Lung abnormalities characteristic for COVID-19 were detected in CT in 53 (84%) patients. The sensitivity and specificity of bedside HUD examination for detecting lung pathologies was 0.92 and 0.90, respectively. Increased number of B-lines had a sensitivity of 0.81, specificity 0.83 for the ground glass symptom in CT examination (AUC 0.82; p < 0.0001); pleural thickening sensitivity 0.95, specificity 0.88 (AUC 0.91, p < 0.0001); lung consolidations sensitivity 0.71, specificity 0.86 (AUC 0.79, p < 0.0001). In 20 patients (32%), pulmonary embolism was confirmed. RV was dilated in HUD examination in 27 patients (43%), CUS was positive in two patients. During HUD examination, software-derived LV function analysis failed to measure LVEF in 29 (46%) cases. HUD proved its potential as the first-line modality for the collection of heart-lung-vein imaging information among patients with severe COVID-19. HUD-derived diagnosis was especially effective for the initial assessment of lung involvement. Expectedly, in this group of patients with high prevalence of severe pneumonia, HUD-diagnosed RV enlargement had moderate predictive value and the option to simultaneously detect lower limb venous thrombosis was clinically attractive. Although most of the LV images were suitable for the visual assessment of LVEF, an AI-enhanced software algorithm failed in almost 50% of the study population.

Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

Prognostic Role of Sonographic Decongestion in Patients with Acute Heart Failure with Reduced and Preserved Ejection Fraction: A Multicentre Study.

We investigated the role of the dynamic changes of pulmonary congestion, as assessed by sonographic B-lines, as a tool to stratify prognosis in patients admitted for acute heart failure with reduced and preserved ejection fraction (HFrEF, HFpEF). In this multicenter, prospective study, lung ultrasound was performed at admission and before discharge by trained investigators, blinded to clinical findings. We enrolled 208 consecutive patients (mean age 76 [95% confidence interval, 70-84] years), 125 with HFrEF, 83 with HFpEF (mean ejection fraction 32% and 57%, respectively). The primary composite endpoint of cardiovascular death or HF re-hospitalization occurred in 18% of patients within 6 months. In the overall population, independent predictors of the occurrence of the primary endpoint were the number of B-lines at discharge, NT-proBNP levels, moderate-to-severe mitral regurgitation, and inferior vena cava diameter on admission. B-lines at discharge were the only independent predictor in both HFrEF and HFpEF subgroups. A cut-off of B-lines > 15 at discharge displayed the highest accuracy in predicting the primary endpoint (AUC = 0.80, p < 0.0001). Halving B-lines during hospitalization further improved event classification (continuous net reclassification improvement = 22.8%, p = 0.04). The presence of residual subclinical sonographic pulmonary congestion at discharge predicts 6-month clinical outcomes across the whole spectrum of acute HF patients, independent of conventional biohumoral and echocardiographic parameters. Achieving effective pulmonary decongestion during hospitalization is associated with better outcomes.

Trajectory and correlates of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction: insights from PARADISE-MI.

PARADISE-MI examined the efficacy of sacubitril/valsartan in acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion, or both. We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a pre-specified substudy. Patients without prior heart failure (HF) underwent eight-zone LUS and echocardiography at baseline (±2 days of randomization) and after 8 months. B-lines were quantified offline, blinded to treatment, clinical findings, time point, and outcomes. Among 152 patients (median age 65, 32% women, mean LVEF 41%), B-lines were detectable in 87% at baseline [median B-line count: 4 (interquartile range 2-8)]. Among 115 patients with LUS data at baseline and follow-up, B-lines decreased significantly from baseline (mean ± standard deviation: -1.6 ± 7.3; P = 0.018). The proportion of patients without pulmonary congestion at follow-up was significantly higher in those with fewer B-lines at baseline. Adjusted for baseline, B-lines at follow-up were on average 6 (95% confidence interval: 3-9) higher in patients who experienced an intercurrent HF event vs. those who did not (P = 0.001). A greater number of B-lines at baseline was associated with larger left atrial size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular systolic function, and higher tricuspid regurgitation velocity (P-trend <0.05 for all). In this AMI cohort, B-lines, indicating pulmonary congestion, were common at baseline and, on average, decreased significantly from baseline to follow-up. Worse pulmonary congestion was associated with prognostically important echocardiographic markers.

Lung ultrasound in congestion assessment of patients with advanced heart failure referred for heart transplant: Correlations with right heart catheterization findings

BackgroundIn advanced heart failure (HF), diagnostic performance of physical exam may be poor. Physical examination associated with lung ultrasound (LUS) may be an important tool to facilitate congestion screening. ObjectiveTo evaluate performance of LUS for congestion screening in advanced HF referred for transplant, as compared to findings of right heart catheterization (RHC). MethodsProspective study of 23 subjects with advanced HF referred for RHC. LUS was performed in association with clinical congestion score (CCS), analogue-visual dyspnea scale (AVDS) and presence of trepopnea/bendopnea prior to catheterization. Congestion was assessed by the number of B-lines in the LUS, and by findings of physical examination as well as by NT-proBNP serum values. ResultsCongestion was present in 43.4 % of patients by LUS (B-lines ≥ 15), as compared to 21.7 % by CCS (score greater than or equal to 5), 56.5 % by NT-proBNP (>1000 pg/ml), and 60.8 % by pulmonary capillary wedge pressure (PCWP) (>15 mm Hg). The number of B-lines was correlated to cardiac index (CI) (rho = −0.619; p 0.002), but not with PCWP (rho 0.190; p 0.386), RAP (rho −0.244; p 0.262), CCS (rho 0.198; p 0.36) and neither with NT-proBNP (rho 0.282; p 0.193). Otherwise, NT-proBNP was correlated with PCWP (rho = 0.636; p = 0.001) and with CI (rho −0.667 p 0.001). ConclusionsIn advanced HF patients referred for transplant, number of B-lines in LUS was not correlated with PCWP or RAP. Advanced HF patients seem to have increased filling pressures, but no interstitial pulmonary congestion that LUS could detect.

Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review.

Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. The included studies were heterogeneous and of relatively limited quality.

Utility of lung ultrasound in selecting older patients with hyperinflammatory phase in COVID-19 pneumonia. A monocentric, cross-sectional pilot study

Background. Cytokine dysregulation plays a critical role in COVID-19, and its timely recognition is pivotal for a favourable outcome, typically in the oldest patient. Lung ultrasound (LUS) has been proven to be an easy-toperform, accurate tool for detecting COVID-19 pneumonia. The current study aimed to evaluate the relationship between inflammatory markers and pulmonary injury assessed by LUS in older patients with COVID-19. Methods. We consecutively evaluated older patients (age ≥ 65 years) hospitalized for COVID-19 pneumonia in our tertiary care hospital. All the patients underwent LUS, physical examination, and blood tests. LUS score for monitoring aeration, based on the number of B-lines for each scanned zone was assessed. Kendall’s Correlation was calculated to verify the relationship between LUS and inflammation markers. A 7.5 mg/dl Hs-CRP cut-off was set to define the “hyper-inflammation” state. Finally, a receiver operating curve (ROC) was evaluated to define a cytokine storm – LUS-defined cut-off. Results. Overall, 65 older patients [mean (SD), 82.0 (6.9) years] were included in the analysis. LUS score was related inversely to PaO2/FiO2 ratio at admission (tau -0.29, p &lt; 0.01) and nadir (tau -0.21, p &lt; 0.01), and positively to Hs-CRP (tau 0.35, p &lt; 0.001). An indexed LUS score higher than 0.8 was highly predictive of cytokine storm (AUROC 0.78, p &lt; 0.001; Sensitivity 86%, Specificity 68%)Conclusions. Lung involvement evaluated by LUS correlates directly with inflammatory markers and inversely with PaO2/ FiO2 ratio. LUS values qualified as an independent predictor of cytokine storm, and a score greater than 0.8 is the most predictive cut-off.

Pre-Dialysis B-Line Quantification at Lung Ultrasound Is a Useful Method for Evaluating the Dry Weight and Predicting the Risk of Intradialytic Hypotension.

Intradialytic hypotension (IDH) is a frequent and well-known complication of hemodialysis, occurring in about one third of patients. An integrated approach with different methods is needed to minimize IDH episodes and their complications. In this prospective observational study, recruited patients underwent a multiparametric evaluation of fluid status through a lung ultrasound (LUS) with the quantification of B-lines, a physical examination, blood pressure, NT-proBNP and chest X-rays. The evaluation took place immediately before and at the end of the dialysis session, and the patients were divided into IDH and no-IDH groups. We recruited a total of 107 patients. A pre-dialysis B-line number ≥ 15 showed a high sensitivity in fluid overload diagnosis (94.5%), even higher than a chest X-ray (78%) or physical examination (72%) alone. The identification at the beginning of dialysis of &lt;8 B-lines in the overall cohort or &lt;20 B-lines in patients with NYHA 3-4 class are optimal thresholds for identifying those patients at higher risk of experiencing an IDH episode. In the multivariable analysis, the NYHA class, a low pre-dialysis systolic BP and a low pre-dialysis B-line number were independent risk factors for IDH. At the beginning of dialysis, the B-line quantification at LUS is a valuable and reliable method for evaluating fluid status and predicting IDH episodes. A post-dialysis B-line number &lt;5 may allow for an understanding of whether the IDH episode was caused by dehydration, probably due to due to an overestimation of the dry weight.

Evaluation of lung ultrasound to detect volume overload in children undergoing dialysis.

Lung ultrasound is a well-established technique to assess extravascular lung water, a proxy for volume status, in the adult population. Despite its utility, the data are limited supporting the use of ultrasound to evaluate fluid volume status among pediatric patients. Our study uses a simplified ultrasound protocol to evaluate changes in extravascular lung water, represented by b-lines, among pediatric patients undergoing hemodialysis. This prospective single-center study included children from birth to 18years of age. The number of b-lines per ml/kg of fluid removed was compared prior to, at the midpoint, and following termination of dialysis. An 8-zone protocol was utilized, and b-lines were correlated to hemoconcentration measured by the CRIT-LINE® hematocrit. Six patients with a total of 26 hemodialysis sessions were included in this study. The b-line measurements post-dialysis were 2.27 (p < 0.001; 94%CI -3.31, -1.22) lower relative to pre-dialysis. The number of b-lines was reduced by 1.69 (p < 0.001; -2.58, -0.80) between pre-dialysis and at the midpoint of dialysis and by 0.58 (p = 0.001; -0.90, -0.24) between the midpoint of dialysis and post-dialysis. A 1mL/kg fluid loss correlated to a decrease in the original b-lines by 0.079. An inverse relationship (r = -0.54; 95% CI: -0.72, -0.34; p < 0.001) was noted between the b-lines and the patients' hematocrit levels. A simplified 8-zone ultrasound protocol can assess fluid volume change in real time and correlates with hematocrit levels obtained throughout dialysis. This provides a valuable method for monitoring fluid status in volume overloaded patient populations. A higher resolution version of the Graphical abstract is available asSupplementary information.

Pulmonary congestion during Exercise stress Echocardiography in Hypertrophic Cardiomyopathy

BackgroundB-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, have not been systematically evaluated in patients with hypertrophic cardiomyopathy (HCM).AimTo assess the clinical, anatomical and functional correlates of pulmonary congestion elicited by exercise in HCM.MethodsWe enrolled 128 HCM patients (age 52 ± 15 years, 72 males) consecutively referred for ESE (treadmill in 46, bicycle in 82 patients) in 10 quality-controlled centers from 7 countries (Belgium, Brazil, Bulgaria, Hungary, Italy, Serbia, Spain). ESE assessment at rest and peak stress included: mitral regurgitation (MR, score from 0 to 3); E/e’; systolic pulmonary arterial pressure (SPAP) and end-diastolic volume (EDV). Change from rest to stress was calculated for each variable. Reduced preload reserve was defined by a decrease in EDV during exercise. B-lines at rest and at peak exercise were assessed by lung ultrasound with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥ 2.ResultsLUS was feasible in all subjects. B-lines were present in 13 patients at rest and in 38 during stress (10 vs 30%, p < 0.0001). When compared to patients without stress B-lines (n = 90), patients with B-lines (n = 38) had higher resting E/e’ (14 ± 6 vs. 11 ± 4, p = 0.016) and SPAP (33 ± 10 vs. 27 ± 7 mm Hg p = 0.002). At peak exercise, patients with B-lines had higher peak E/e’ (17 ± 6 vs. 13 ± 5 p = 0.003) and stress SPAP (55 ± 18 vs. 40 ± 12 mm Hg p < 0.0001), reduced preload reserve (68 vs. 30%, p = 0.001) and an increase in MR (42 vs. 17%, p = 0.013) compared to patients without congestion. Among baseline parameters, the number of B-lines and SPAP were the only independent predictors of exercise pulmonary congestion.ConclusionsTwo-thirds of HCM patients who develop pulmonary congestion on exercise had no evidence of B-lines at rest. Diastolic impairment and mitral regurgitation were key determinants of pulmonary congestion during ESE. These findings underscore the importance of evaluating hemodynamic stability by physiological stress in HCM, particularly in the presence of unexplained symptoms and functional limitation.

To B or not to B. The rationale for quantifying B-lines in pediatric lung diseases.

Lung ultrasound (LUS) is emerging as adjunct tool to be used during clinical assessment. Among the different hallmarks of LUS, B-lines are well known artifacts, which are not correlated with identifiable structures, but which can be used for pathological classification. The presence of multiple B-lines is a sonographic sign of lung interstitial syndrome. It has been demonstrated in adults that there is a direct correlation between the number of B-lines and the severity of the interstitial involvement of lung disease. Counting B-lines is an attempt to enrich the clinical assessment and clinical information, beyond obtaining a simple dichotomous answer. Semiquantitative or quantitative B-line assessment has been shown to correlate with fluid overload and demonstrated prognostic implications in specific neonatal and pediatric conditions. LUS with quantitative B-lines assessment is promising. Current evidence allows for quantification of B-lines in a limited number of neonatal and pediatric diseases.

Lung ultrasound assessment of pulmonary edema in neonates with chronic lung disease before and after diuretic therapy.

Bronchopulmonary dysplasia (BPD) is characterized by lung injury with varying degrees of disrupted alveolarization, vascular remodeling, inflammatory cell proliferation, and pulmonary edema. Diuretics are often used to ameliorate the symptoms or progression of BPD. Our primary objective was to use lung ultrasound (LUS) to determine if diuretics decrease pulmonary edema in infants with BPD. The secondary objective was to assess changes in respiratory support during the first week after initiation of diuretics. Premature infants requiring noninvasive respiratory support and starting diuretic therapy for evolving BPD were compared with a similar group of infants not receiving diuretics (control). For the diuretic group, LUS exams were performed before and on Days 1, 3, and 6 after initiation of treatment. For the control group, LUS was performed at equivalent time points. A composite pulmonary edema severity (PES) score of 0-5 was calculated based on the total number of B-lines in six scanned areas. Respiratory support parameters (FiO2 , nasal cannula flow, or CPAP) were also recorded. Infants in the diuretic (n = 28) and control (n = 23) groups were recruited at median corrected gestational ages of 34.2 (33.3-35.9) and 34.0 (33.4-36.3) weeks, respectively (p = 0.82). PES scores, FiO2 , and respiratory flow support decreased significantly from Days 0 to 6 (p < 0.0001, p = 0.001, and p = 0.01, respectively) in the diuretic group, but not in the control group. Diuretic use is associated with decreased pulmonary edema and improved oxygenation in infants with BPD during the first week of treatment.

Lung ultrasound predicts left-sided filling pressures in patients with cardiogenic shock admitted to the cardiac intensive care unit

Abstract Background Left and right filling pressures, as well as cardiac output, are key targets in optimising treatment of cardiogenic shock (CS). Invasive pulmonary artery catheters can provide these data but are associated with complications and are not available in all hospital settings. Lung ultrasound (LUS) can detect pulmonary congestion in patients with heart failure (HF) and may be an alternative to invasive monitoring. We assessed the correlation between LUS score and invasive haemodynamic parameters in patients with CS admitted to the cardiac intensive care unit (CICU) of a North American cardiac centre. Methods We prospectively evaluated consecutive patients who underwent pulmonary artery catheter insertion in the CICU. Haemodynamic parameters including right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were measured and cardiac output (CO) was calculated using the thermodilution method. This was immediately followed by an 8-zones LUS done by a critical care cardiologist who was blinded to the invasive hemodynamic measurements. The LUS score was calculated by counting the total number of B-lines in all 8 zones, with a higher score indicating greater congestion. Correlations between LUS score and hemodynamic parameters were evaluated using Pearson's correlation. Results Ninety-six measurements from 60 patients were included, aged 58±14 years with 27% female. The most common diagnosis at admission was cardiogenic shock, followed by acute myocardial infarction and HF exacerbation. Most patients were at SCAI stages C and D at the time of assessment. The mean number of B-lines at LUS was 10.1±8.2. Mean RAP was 8.5±4.6 mmHg, PCWP 16.2±6.3 mmHg and CO of 5.0±1.8 L/min. The total number of B-lines was correlated with PCWP (r=0.66, P&amp;lt;0.001, see Figure 1), RAP (r=0.26, P&amp;lt;0.001) and cardiac output (r=−0.23, p=0.02). Due to the correlation of B-lines in LUS with PCWP, we then evaluated the area under the ROC of the LUS to identify patients with PCWP ≥15 mmHg. The number of positive zones (≥3 B-lines) showed an AUC of 0.81 (0.72–0.89), P&amp;lt;0.001. In 36 patients, we had repeated measurement with more than 12 hours apart. The delta change in PCWP was correlated with delta change in the number of B-lines (r=0.59, P&amp;lt;0.001). Conclusion Elevated LUS score in patients with CS is associated with worse invasively-measured LV filling pressures, but less so with RAP or CO. LUS can serve as a useful adjunct to the clinical assessment of patients with CS who do not receive invasive hemodynamic monitoring, either at a single timepoint or to detect changes in clinical status over time, to guide ongoing management. Funding Acknowledgement Type of funding sources: None.

Pre-discharge B-lines at bedside predicts 30-day and multiple 90-day hospital re-admission in patients admitted for acute decompensated heart failure

Abstract Background Inadequate decongestion at index admission for Acute Decompensation of Heart Failure (ADHF) is a common cause of adverse outcomes. A bedside 9-zone Lung and IVC ultrasound assessment (LUICA) may help to guide decongestion and reduce hospital readmission or mortality. Purpose To identify predictors of multiple 90-day hospital representations or mortality based on a bedside handheld 9-zone LUICA volume assessment obtained by HF nurses. Methods Patients admitted for ADHF, enrolled in the RISK-HF registry and undergoing pre-discharge LUICA, were assessed for 90-day readmission and/or mortality. The primary outcome of this observational report was prediction of multiple hospital representations based on pre-discharge volume status. The LUICA was performed with a hand-held ultrasound (HHU) device (Lumify, Philips) by trained HF-nurses. Functional capacity was measured with Duke Activity Status Index (DASI). Paired t-tests were used to compare mean differences. Logistic and linear regression were used to study relationships of outcomes with clinical characteristics. Cox regression was used to analyse time to repeated readmission or death. Analysis conducted with SPSS statistics V27 and STATA SE16. Results Of 302 ADHF patients, 67 readmitted within 30-days (age 76±8.5; men, 60%; HFrEF; 44%) and 235 did not readmit within 30-days (age 72±14; 57% men; 52% HFrEF). Readmission occurred in older patients (p=0.05), with pre-discharge signs of residual congestion that was based on the number of b-lines (p&amp;lt;0.01) (Table 1). Pre-discharge B-lines were predictive of DAOOH (β −0.41, −0.6, −0.22, p&amp;lt;0.01) and of multiple 90-day hospital readmissions (β 0.03, 0.018, 0.05, p&amp;lt;0.01), independently of 30-day event risk score, number of readmissions the preceding 12 months and age at index admission (Table 2). Number of B-lines at discharge was also associated with repeated readmission or death (HR=1.02 [1.01, 1.04]) in time-to-event analysis, independent of any other factors. Conclusion Pre-discharge residual congestion defined by the number B-lines increases the likelihood of multiple 90-day adverse outcomes. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The University of MelbourneBaker Heart &amp; Diabetes Institute

Trajectory of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction and association with cardiac structure and function

Abstract Background The PARADISE-MI trial examined the efficacy of sacubitril/valsartan in patients with acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion or both. Little is known about the trajectory and echocardiographic correlates of pulmonary congestion in this population. Purpose We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a subset of patients enrolled in PARADISE- MI. Methods Participants underwent 8-zone LUS at baseline and 8 months. B-lines were quantified offline, blinded to treatment group, clinical findings, timepoint and outcomes by a core laboratory. Paired t-tests, chi-squared tests, and linear regression analyses were conducted. Results Among 152 patients (median age 65 years, 32% women, 35% obese, mean LVEF 41%), any B-lines were detectable in 87%, the median sum of B-lines in 8 zones was 4 [IQR 2–8], and 67% had ≥3 B-lines indicative of congestion. Greater number of B-lines at baseline was associated with larger left atrial (LA) size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular (RV) systolic function, and higher tricuspid regurgitation velocity (P trend &amp;lt;0.05 for all) (Figure 1). Among 115 patients with 8-month LUS data, there was a significant decline in number of B-lines from baseline (mean ± SD: −1.6±7.3; p=0.018). Adjusted for baseline, B-lines at follow-up were on average 6 (95% CI: 3, 9) higher in a patient who experienced an intercurrent heart failure (HF) event than a non-HF patient (p=0.001). Among 75 patients with ≥3 B-lines at baseline, a decrease in B-lines to &amp;lt;3, indicating decongestion, occurred in 37% and was similar in the sacubitril/valsartan and ramipril groups (36% vs. 39%, p=0.83). Conclusions In this post-AMI cohort, sonographic B-lines, indicating pulmonary congestion, were common at baseline and were significantly higher at follow-up in those who developed HF. Worse pulmonary congestion at baseline was associated with prognostically important echocardiographic markers of LV filling pressure, pulmonary pressure, and RV function. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Novartis

Heterogeneous mechanisms of pulmonary congestion in hypertrophic cardiomyopathy unmasked by comprehensive exercise stress echocardiography

Abstract Background B-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, are present in 1 out of 3 patients with hypertrophic cardiomyopathy (HCM). Aim To assess the functional and anatomical correlates of exercise B-lines in HCM. Methods We enrolled 191 HCM patients (age 53±15 years, 123 males) consecutively referred for ESE (treadmill in 74, bicycle in 117 patients) in 11 quality-controlled centers from 8 countries. ESE assessment at rest and peak stress included: left ventricular (LV) outflow tract gradient, left atrial (LAVi) and LV end-diastolic volume index (EDVi), mitral regurgitation (MR, score from 0 to 3); E/e'; systolic pulmonary arterial pressure (SPAP) and LV force (LV outflow tract gradient+systolic blood pressure/LV end-systolic volume). B-lines at rest and at peak exercise were assessed by LUS with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥2. Results LUS was feasible in all subjects. B-lines were present in 55 (29%) patients during stress. When compared to patients without stress B-lines (n=136), patients with B-lines (n=55) at peak exercise had lower peak EDVi (43±17 vs 52±18 ml/m2, p=0.003) higher peak E/e' (16±6 vs 12±5, p&amp;lt;0.001), increase in MR (34 vs 12%, p=0.001), greater stress LAVi (43±14 vs 37±14 ml/m2, p=0.003) and stress SPAP (56±18 vs 40±12 mm Hg p&amp;lt;0.0001): see Figure. Among baseline parameters, the number of B-lines (OR: 7.53, 95% CI 1.21–46.72 p=0.03), LAVi (OR: 1.05, 95% CI 1.00–1.09 p=0.04), and LV force (OR: 1.36, 95% CI 1.04–1.79 p=0.03) were the independent predictors of exercise pulmonary congestion. Conclusion HCM patients with pulmonary congestion on exercise show different, and not mutually exclusive mechanisms of diastolic dysfunction and worsening mitral regurgitation. These different hemodynamic mechanisms may require personalized therapeutic actions beyond a pulmonary decongestion therapy with diuretics. Funding Acknowledgement Type of funding sources: None.

Prognostic value of rest B-lines with the simplified 4-site scan for predicting survival: incremental value over transthoracic echocardiography

Abstract Background Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest. Methods After preliminary exclusion of 154 patients lost to follow-up, we analyzed transthoracic echocardiography (TTE) plus LUS (4-site simplified scan) data in 5165 subjects (age 64±11 years) referred to 19 certified centers of 9 countries for known or suspected coronary artery disease (n=3891, 75%), dyspnea (n=591, 12%), or screening in asymptomatic patients with risk factors (n=667, 13%). We analyzed the anterior and lateral hemi-thoraces, scanning from mid-axillary to mid-clavicular lines on the third intercostal space. B-lines score ranged from 0 (normal) to 40 (severely abnormal). By selection, follow-up information was available in all. All-cause death was the predetermined end-point. Results Feasibility of B-lines was 100% in all subjects. B-lines (median) were 0.1 [0–1]. Rest B-lines (≥2) were present in 863 patients (16.7%). Ejection fraction was 61±10%. After a median follow-up of 690 (Interquartile range 420–1065) days, 96 all-cause deaths occurred. Two-year mortality was 3.6% in patients with and 1.5% in patients without B-lines (p&amp;lt;0.001) and increased progressively with the increasing number of B-lines, from 2.4% in mild (2–4, n=630), 5.0% in moderate (5–9, n=160) and 8.2% in patients with severe (≥10, n=73) B-lines (see figure). At multivariable analysis, rest B lines (HR 1.812, 95% CI: 1.165–2.916, p=0.008) and ejection fraction (HR 0.987, 95% CI: 0.976–0.998, p=0.020) were independent predictors of all-cause death, in addition to age (HR 1.045, 95% CI: 1.023–01.067, p&amp;lt;0.001) and diabetes (HR 1.643, 95% CI: 1.079–2.503, p=0.021). Conclusion In all-comers referred for TTE, resting B-lines assessed by focused LUS with the simplified 4-site scan are detected in 1 out of 4 patients with symptos or coronary risk factors and are associated with worse survival. The severity of pulmonary congestion predicts the severity of outcomes. The prognostic value of resting B-lines is independent and additive over standard clinical and TTE predictors such as diabetes and ejection fraction. Focused LUS for pulmonary congestion can easily be incorporated in standard TTE examination. Funding Acknowledgement Type of funding sources: None.

Phenotyping Acute Decompensated Heart Failure (ADHF)by a cardiac speckle tracking analysis

Abstract Background The global longitudinal strain (GLS) evaluation by Speckle Tracking Echocardiography (STE) is an established non-invasive, highly reproducible echocardiographic prognostic index in Heart Failure (HF). In acute decompensated heart failure (ADHF), GLS has proved to have greater prognostic value than left ventricular ejection fraction (LVEF) in the categorization of HF. However, how GLS may change over hospital staying in ADHF and how it correlates with Left Atrial (LA) functioning and contractile reserve in this cohort of subjects is currently undefined. Aims To evaluate, in a cohort of ADHF patients, GLS extent of changes after targeted anti-congestion therapy and its correlation with LA mechanics and reservoir function. Methods Eighty-five ADHF patients (mean age 75.6±10.4 years, 59% males) were prospectively enrolled within 24 hours from admission to the emergency department (ED). In either the acute phase and at pre-discharge all patients underwent laboratory tests, Lung Ultrasonography (LUS), M-Mode, 2-Dimensions and Doppler Echocardiography. LA dynamics assessment was based on the evaluation of LA strain, particularly through Global-Peak Atrial Longitudinal Strain (GPALS). Strain analysis by STE was performed offline. Results From admission to discharge, despite decongestion as shown by a significant reduction of the number of B-lines measured at LUS and NT-proBNP at blood tests (B-lines: 22.2±17.1 vs. 6.5±5 p&amp;lt;0.001; NT-proBNP: 8738±948 ng/l vs 4227±659 ng/l p&amp;lt;0.001), we observed only minimal and non-significant changes in the average GLS (from −12.2±4% at admission to −12.5±3.8% at discharge; p=0.8) and GPALS (from 13.2±7.6% at admission to 13.6±7.8% at discharge; p=0.77) (Table 1). Interestingly, when evaluated with Pearson's coefficient, in the whole population a significant direct correlation was observed between GLS and GPALS values at discharge (r=0.6, 95% Confidence Interval (CI) 0.55–0.7; p&amp;lt;0.001) (Figure 1) as well as between ΔGLS and ΔGPALS (r=0.42 95% CI 0.21–0.59, p=0.02). Conclusions In patients hospitalized for ADHF a significant impairment of GLS occurs and no improvement is observed at discharge after decongestion. The LA dynamics correlates with, and is likely involved in, this lack of changes. In this subset of patients, the dissociation between decongestion and LV and LA dynamics evaluated by strain analysis suggest the importance to monitor these functional indicators in order to improve risk stratification and reduce early re-hospitalization for AHF. Funding Acknowledgement Type of funding sources: None.

Screening value of lung ultrasound in connective tissue disease related interstitial lung disease

BackgroundInterstitial lung disease (ILD) is a common pulmonary complication of connective tissue disease (CTD) that can lead to poor quality of life and prognosis. ObjectivesTo explore the screening value of lung ultrasound (LUS) for connective tissue disease-associated interstitial lung disease (CTD-ILD). MethodsData of patients with CTD were collected, and each patient underwent LUS, high-resolution computed tomography (HRCT), and pulmonary function tests. Considering HRCT is the gold standard for diagnosing CTD-ILD, patients were divided into CTD-ILD and CTD-non-ILD groups. The LUS and HRCT results were assessed using semiquantitative and Warrick scores, respectively. Pulmonary function results were also collected. Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of LUS diagnosis. Spearman correlation analysis was used to analyze the correlation between LUS, HRCT, and lung function indices. ResultsA total of 88 patients (65 with CTD-ILD and 23 with CTD-non-ILD) were included in this study. The sensitivity and specificity of LUS for the diagnosis of CTD-ILD were 86.60% and 82.60%, respectively, which was consistent with the HRCT results (P < 0.05). The LUS results (total number of B-lines, frequency of B-line, pleural thickness, and pleural-line irregularity) were positively correlated with the HRCT Warrick score (r = 0.77, 0.76, 0.65 and 0.71, P < 0.05). ConclusionsLUS may be a promising tool for screening patients with CTD-ILD.

Incremental prognostic value of lung ultrasound on contemporary heart failure risk scores.

Introduction: Over the last decades, several scores have been developed to aid clinicians in assessing prognosis in patients with heart failure (HF) based on clinical data, medications and, ultimately, biomarkers. Lung ultrasound (LUS) has emerged as a promising prognostic tool for patients when assessed at discharge after a HF hospitalization. We hypothesized that contemporary HF risk scores can be improved upon by the inclusion of the number of B-lines detected by LUS at discharge to predict death, urgent visit, or HF readmission at 6- month follow-up. Methods: We evaluated the discrimination improvement of adding the number of B-lines to 4 contemporary HF risk scores (Get with the Guidelines -GWTG-, MAGGIC, Redin-SCORE, and BCN Bio-HF) by comparing the change in the area under the receiver operating curve (AUC), the net reclassification index (NRI), and the integrated discrimination improvement (IDI). The population of the study was constituted by the 123 patients enrolled in the LUS-HF trial, adjusting the analyses by the intervention. Results: The AUC of the GWTG score increased from 0.682 to 0.789 (p = 0.02), resulting in a NRI of 0.608 and an IDI of 0.136 (p < 0.05). Similar results were observed when adding the number of B-lines to the MAGGIC score, with an AUC that increased from 0.705 to 0.787 (p < 0.05). This increase translated into a NRI of 0.608 and an IDI of 0.038 (p < 0.05). Regarding Redin-SCORE at 1-month and 1-year, the AUC increased from 0.714 to 0.773 and from 0.681 to 0.757, although it did not reach statistical significance (p = 0.08 and p = 0.06 respectively). Both IDI and NRI were significantly improved (0.093 and 0.509 in the 1-month score, p < 0.05; 0.056 and 0.111 in the 1-year score, p < 0.05). Lastly, the AUC for the BCN Bio-HF score increased from 0.733 to 0.772, which was statistically non-significant, with a NRI value of 0.363 (p = 0.06) and an IDI of 0.092 (p < 0.05). Conclusion: Adding the results of LUS evaluated at discharge improved the predictive value of most of the contemporary HF risk scores. As it is a simple, fast, and non-invasive test it may be recommended to assess prognosis at discharge in HF patients.