Transthoracic Ultrasonography Research Articles

Implementation of evidence on management of pleural diseases: insights from a territory-wide survey of clinicians in Hong Kong

BackgroundMajor advances in management of common pleural diseases have taken place in the past decade. However, pleural diseases are often managed by physicians of diverse training background and research on implementation of new knowledge is scanty. We aim to evaluate the practice pattern in pleural medicine among physicians in Hong Kong, for identification of possible gaps for clinical service improvement.MethodsThe Hong Kong Thoracic Society undertook a cross-sectional questionnaire survey in 2019, targeting clinicians of various subspecialties in internal medicine and levels of experience (basic and higher trainees, specialists) from twelve regional hospitals of diverse service scopes throughout Hong Kong. Respondents were selected by non-probability quota sampling. The questionnaire tool consisted of 46 questions covering diagnostic and therapeutic aspects of common pleural diseases. The responses were anonymous, and analysed independently using SPSS statistics software.ResultsThe survey collected 129 responses, 47(36%) were from clinicians specialized in respiratory medicine. Majority of the respondents (98%) managed pleural diseases, including performing pleural procedures in their practice. Fifty-five percent of all the respondents had not received any formal training in transthoracic ultrasonography. A significant proportion of clinicians were unaware of pleuroscopy for investigation of exudative pleural effusion, indwelling pleural catheter for recurrent malignant pleural effusion, and combined intra-pleural Alteplase plus DNase for treatment of pleural infection (30%, 15% and 70% of non-respiratory clinicians respectively). Significant heterogeneity was found in the management of pleural infection, malignant pleural effusion and pneumothorax among respiratory versus non-respiratory clinicians. Contributing factors to the observed heterogeneity included lack of awareness or training, limited accessibility of drugs, devices, or dedicated service support.ConclusionSignificant heterogeneity in management of pleural diseases was observed among medical clinicians in Hong Kong. Continuous medical education and training provision for both specialists and non-specialists has to be strengthened to enhance the implementation of advances, improve quality and equity of healthcare provision in pleural medicine.

Correlation between diaphragmatic mobility by transthoracic ultrasound and echocardiography findings in patients with idiopathic pulmonary fibrosis

Background Idiopathic pulmonary fibrosis (IPF) is known as a particular pattern of persistent gradually developing fibrosing interstitial pneumonia of unspecified cause that takes place mainly in elder adults, is restricted to the lungs, and is correlated with the radiological and/or histopathological pattern of usual interstitial pneumonia. Patients with IPF exhibit characteristic features regarding the respiratory and cardiac muscle function. The lack of an association between diaphragmatic mobility and echocardiography findings of right and left ventricle functions in patients with IPF was unexpected as transthoracic ultrasound (US) and echocardiography are feasible, reproducible, noninvasive, and largely adopted in the clinical practice and in clinical trials. Objective To correlate between diaphragmatic mobility using transthoracic US and ventricular functions using echocardiography in patients with IPF. Patients and methods A prospective case–control study was conducted in which 40 patients with IPF and 10 controls underwent transthoracic US assessment of diaphragmatic excursion and echocardiography study, and then the results were correlated. Results There was a statistically significant decrease in deep breathing excursion, right ventricle functional area change, tricuspid annular plane systolic excursion, and ejection fraction in addition to an increase in pulmonary artery systolic pressure among the study group. Both normal breathing excursion and deep breathing excursion have a positive correlation with right ventricle functional area change and tricuspid annular plane systolic excursion, whereas a negative correlation was seen with age and pulmonary artery systolic pressure in both study and control groups. Conclusions Transthoracic US assessment of diaphragmatic mobility can clearly reflect the right ventricle function in patients with IPF.

Utility of high-frequency B-mode and contrast-enhanced ultrasound for the differential diagnosis of benign and malignant pleural diseases: a prospective study.

Pleural disease is a prevalent condition. As precision therapy advances, noninvasive imaging modalities play even more important roles in the evaluation of pleural diseases. This study investigated the diagnostic capabilities of high-frequency B-mode ultrasound (US) and contrast-enhanced US (CEUS) in terms of differentiating between benign and malignant pleural diseases. Patients with unexplained thickened pleurae were prospectively analyzed via transthoracic US. High-frequency B-mode US was used to derive the pleural thickness, morphology, and echogenicity. We analyzed the high-frequency CEUS data including the enhancement mode and time intensity curve (TIC). The cause of pleural thickening was confirmed by pleural biopsy and follow-up after the biopsy. We analyzed the differences in various ultrasonic features between the malignant and benign groups. Moreover, we plotted receiver operator curves (ROCs) and obtained the area under the curves, sensitivities, and specificities of all significant continuous variables. Multivariate logistic regression was used to assess the combined usefulness of multiple US indicators in terms of predicting malignant pleurae. Thirty malignant and twenty benign thickened pleurae were finally diagnosed via pleural biopsy and at least six months of follow-up. The pleural morphology and enhancement modes significantly differed between the two groups (all P<0.05). The thickness derived from B-mode US and CEUS were significantly thicker in the malignant group (both P<0.05). Arrival time (AT) and the time to peak (TTP) of TIC were significantly shorter in the malignant group, whereas peak intensity and the area under the TIC were significantly higher in the malignant group (all P<0.05). The area under the ROC for pleural thickness derived from B-mode US was 0.819; pleural thickness derived from CEUS was 0.848; AT was 0.804; TTP was 0.750; peak intensity was 0.745; the area under the TIC was 0.743; and the combined various B-mode and CEUS parameter was 0.975. Pleural thickness, morphology, enhancement mode, and the TIC of high-frequency US aided the differentiation of benign from malignant pleural diseases. Combined analysis of US indicators further improved the diagnostic capability.

Lung consolidation as an acoustic window to superior vena cava by transthoracic ultrasonography in the intensive care unit.

Lung consolidation as an acoustic window to superior vena cava by transthoracic ultrasonography in the intensive care unit.

To scan or not to scan? The economics of transthoracic ultrasonography for 'whole-flock' ovine pulmonary adenocarcinoma screening in UK sheep flocks.

Transthoracic ultrasonography (TTUS) is currently the only widely used method to diagnose suspected preclinical or subclinical cases of ovine pulmonary adenocarcinoma/Jaagsiekte (OPA) in live sheep. However, the economic impact of using TTUS as a screening test has not been described previously. Test characteristics for TTUS in a low-prevalence situation were obtained from a previous study of 1074 breeding ewes that underwent TTUS with an experienced operator. The economic impact was modelled using a 10,000-iteration partial budget simulation and probability sensitivity analysis to explore the relative influence of model variables. In flocks of this size, culling true-positive and false-positive cases resulted in an estimated median net loss of £4647 (interquartile range: £3537-£6006), determined primarily by replacement ewe value and the cost of TTUS per ewe. The results of this study emphasise that great caution should be exercised by practitioners when determining if TTUS is appropriate as a screening test for OPA in low-prevalence flocks or subpopulations within a flock, such as younger age groups, where the losses incurred through the inadvertent culling of healthy sheep may significantly exceed any benefit derived from culling preclinical/subclinical cases.

How useful is transthoracic ultrasonography for detecting ovine pulmonary adenocarcinoma in sheep?

How useful is transthoracic ultrasonography for detecting ovine pulmonary adenocarcinoma in sheep?

Accuracy of Transthoracic Ultrasound in the Diagnosis of Different Pleural and Pulmonary Diseases: Zagazig University Experience

Recently, there is an increase application of chest ultrasound to evaluate and monitor pleuropulmonary diseases. Computed tomography (CT) is the gold standard for most different lung pathologies with limitations. This study aims to assess the effectiveness of Chest Ultrasound compared to Computed Tomography in diagnosis of different pleuropulmonary disorders and to define the rules of chest ultrasound in pulmonary medicine. This study was conducted upon randomly selected 110 patients with different pleuropulmonary disorders who were admitted to the respiratory ward and ICU, Zagazig University Hospitals, from April 2018 to April 2020. All patients with abnormal chest X. ray opacities were evaluated for complete history taking, full clinical examination, laboratory investigations, then Chest US was performed on the first day of admission then CT was done as a gold standard for the final diagnosis then results of both Chest US and CT were compared. Compared to CT, Chest US had sensitivity (95.8%) for free pleural effusion diagnosis, specificity (90.3%), and (92.7%) accuracy; for pneumonia, (90.9%), (96.1%), and (94.5%) respectively, while pneumothorax had (81.8%), (98%), and (96.3%) accuracy, respectively; for pulmonary edema, (89.5%), (97.8%), and (96.4%) accuracy, respectively. The US plays a valuable role in the diagnosis of different pleuropulmonary diseases and can be used as the first routine radiological modality in both ward &amp; ICU.

Efficacy of high-throughput transthoracic ultrasonographic screening for on-farm detection of ovine pulmonary adenocarcinoma.

The aim of this study was to evaluate the efficacy of high-throughput on-farm transthoracic ultrasound (TUS) to screen for ovine pulmonary adenocarcinoma (OPA), an infectious ovine disease of increasing concern. No other routine diagnosis of preclinical OPA is available, or any vaccine or treatment. More than 80,000 rapid TUS scans were applied on farms with a history of OPA. The TUS results from a convenience sample of 171 TUS-negative and 269 TUS-positive sheep were compared with postmortem histology/immunohistochemistry results, the 'gold standard' reference test for OPA diagnosis. These results, together with new data on within-flock prevalence, allowed estimation of the efficacy of rapid TUS screening to identify OPA (defined as tumours of larger than 1cm) on-farm. The TUS screening had an estimated specificity of 0.998 (95% confidence interval [CI]: 0.998-0.999) and an estimated sensitivity of between 0.76 (95% CI: 0.72-0.79) and 0.99 (95% CI: 0.97-0.99) depending on the presumed false-negative rate applied to the calculation. High-throughput TUS should be considered for screening to identify individual sheep with OPA and has potential application to indicate flocks at low risk of OPA. However, lower efficacy is likely if conducted by less experienced persons.

New biomarkers for the diagnosis of pleural effusion

BackgroundPersistent undiagnosed effusion is present in approximately 15% of all causes of exudative effusion. Pleural effusion caused by immunoglobulin G4 (IgG4) is a new type of pleural effusion. Tumor markers such as Carcinoembryonic antigen (CEA) may play a role in the diagnosis of malignant pleural effusion. This study aimed to evaluate the use of serum Immunoglobulin G4 and carcinoembryonic antigen in diagnosing pleural effusion.MethodsThis observational descriptive cross-sectional study comprised 89 individuals with exudative pleural effusion who visited the Assiut university hospital's chest department. All patients were examined and asked about their medical history. Also, chest X-ray, MSCT chest, transthoracic ultrasonography, pleural fluid analysis and cytology, serum level of carcinoembryonic antigen, and immunoglobulin G4 were performed. In addition, pleural biopsy, bronchoscopy, and thoracoscopy were performed when required.ResultsIn comparison to another diagnosis, the level of serum IgG 4 was observed to be substantially greater in individuals with IgG4-associated effusion (725± 225.45). Patients with malignant mesothelioma (70± 16.24) and metastatic adenocarcinoma (93.52± 19.34) had lower levels of IgG4. In contrast, the serum level of CEA was significantly higher in individuals with malignant mesothelioma (79.50± 29.47) and metastatic adenocarcinoma (68.71± 28.98). Patients with para-pneumonic effusion had a minor serum level of CEA (0.36 ± 0.26). At cutoff point > 152 mg/dl serum IgG-4 had 100% sensitivity and 94% specificity in the diagnosis of IgG4 related pleural effusion with an overall accuracy of 95.3% and area under the curve of 0.97. At the cutoff point > 5 ng/ml serum CEA had 77% sensitivity and 100% specificity in diagnosing malignant pleural effusion with an overall accuracy of 91.1% and area under the curve of 0.88.ConclusionSerum IgG4 higher than 152 mg/dl has good diagnostic accuracy in cases of undiagnosed pleural effusion. Carcinoembryonic antigen aids in diagnosing malignant pleural effusion with a cutoff point higher than 5 ng/ml in serum.Trial registrationClinicalTrials.gov registration ID NCT03260088

Comparison of superior and inferior vena cava diameter variation measured with transthoracic echocardiography to predict fluid responsiveness in mechanically ventilated patients after abdominal surgery

BackgroundThe volume status of patients after major abdominal surgery constantly varies owing to postoperative diverse issues comprising fluid loss or capillary leakage secondary to systemic inflammatory reaction syndrome, et.al, the precise fluid responsiveness assessment is crucial for those patients. The purpose of this study is to validate the transthoracic ultrasonographic measurement of superior and inferior vena cava variation in predicting fluid responsiveness of mechanically ventilated patients after surgery.MethodsA total of 70 patients undergoing the scheduled major abdominal surgeries in the anesthesia ICU ward were included. The superior vena cava (SVC) collapsibility index (SVCCI), the inferior vena cava distensibility index (dIVC), SVC variation over the cardiac cycle (SVCV), and cardiac output (CO) were measured by transthoracic ultrasonography were recorded before and after fluid challenge test of 5 ml/kg crystalloid within 15 min. The responders were defined as a 15% or more increment in CO.ResultsThirty patients (42.9%) responded to fluid challenge, while the remnant forty patients (57.1%) did not. The areas under the ROC curve (AUC) of SVCCI, dIVC and SVCV were 0.885 (95% CI, 0.786–0.949; P < 0.0001) and 0.727 (95% CI, 0.608–0.827; P < 0.001) and 0.751 (95% CI, 0.633–0.847; P < 0.0001), respectively. AUCdIVC and AUCSVCV were significantly lower when compared with AUCSVCCI (P < 0.05). The optimal cutoff values were 19% for SVCCI, 14% for dIVC, and 15% for SVCV. The gray zone for SVCCI was 20%-25% and included 15.7% of patients, while 7%-27% for dIVC including 62.9% of patients and 9%-21% for SVCV including 50% of patients.ConclusionSuperior vena cava-related parameters measured by transthoracic ultrasound are reliable indices to predict fluid responsiveness. The accuracy of SVCCI in mechanically ventilated patients after abdominal surgery is better than that of dIVC and SVCV.Trial registrationChiCTR-INR-17013093. The initial registration date was 24/10/2017.

Prediction of preoperative intrathoracic adhesions for ipsilateral reoperations: sliding lung sign

IntroductionVideo-assisted thoracic surgery (VATS) for ipsilateral reoperations is controversial, because after the first surgical intervention, pleural adhesions occur frequently in the thoracic cavity and/or chest wall. This study assessed the usefulness of preoperative ultrasonography to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS.Materials and methodsThis was a retrospective, single-center study. Nine patients who underwent thoracic surgery at Vanvitelli Hospitalfrom September 2019 to February 2022, were scheduled for a second VATS surgeryon ipsilateral lung, because of inconclusive intraoperative histologic examination. All nine patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions. We evaluated the lung sliding, since the presence of pleural adhesions does not permit to appreciate it.Statistical analysisHard severe adhesions were observed in all nine patients without sliding lung sign (specificity 100%). In this series, the sensitivity, PPV, and NPV of the sliding lung sign were 93%, 100% and 94% respectively.ResultsThe presence of the lung respiratory changes can be evaluated as the “sliding lung sign” by chest ultrasonography; we believe that the sliding lung sign might also predict intrathoracic adhesion.ConclusionsPreoperative detection of pleural adhesions using transthoracic ultrasonography was useful for ipsilateral secondary pulmonary resection patients undergoing VATS. Using preoperative ultrasonography can improve the safety and feasibility of placing the initial port in VATS.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BackgroundTo assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.MethodsA prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.ResultsAs per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.ConclusionsThe concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

To scan or not to scan? Efficacy of transthoracic ultrasonography for ovine pulmonary adenocarcinoma screening in a large commercial UK sheep flock.

Transthoracic ultrasonography (TTUS) is currently the only widely used method to diagnose preclinical or subclinical ovine pulmonary adenocarcinoma (OPA) in the live sheep. However, little is known about the test characteristics of TTUS. One thousand and seventy-four breeding ewes in a flock with evidence of low OPA prevalence underwent TTUS by an experienced operator. Fifty-one sheep were diagnosed with OPA and underwent gross postmortem examination (PME). Lesions consistent with OPA were found in only 24% (12/51) of the culled ewes. Thirty-five percent (18/51) of culled ewes had gross lesions consistent with other pulmonary disease and 41% (21/51) had no detectable gross lesions on PME. Histopathology and immunohistochemistry confirmed OPA in only the 12 animals identified with OPA lesions from PME. Great caution should be exercised when deciding if TTUS is an appropriate screening test in groups of sheep where OPA prevalence may be anticipated to be low. TTUS is a subjective test and thus individual operator ability will influence the sensitivity and specificity of TTUS for OPA diagnosis while the underlying prevalence influences the eventual positive predictive value.

Detection of left ventricular dysfunction on axial non-contrast chest CT

PurposeTo evaluate the performance of axial non-contrast CT images in detecting systolic and diastolic left ventricular (LV) dysfunction. MethodThis single-center retrospective study assessed 178 participants who underwent transthoracic ultrasonography and had non-contrast chest CT data within three months of ultrasonography. The patients were divided into LV systolic dysfunction (<52% ejection fraction in men and <54% in women), LV diastolic dysfunction (at least three of the following four criteria were met: average E/e' ratio >14; septal e' <7 cm/s or lateral e' <10 cm/s; peak tricuspid regurgitation velocity >2.8 m/s; or left atrial maximum volume index >34 ml/m2), and normal LV function groups. CT parameters were evaluated as predictive factors for LV dysfunction. These parameters were: I, maximum minor axis diameter of the LV lumen; II, I plus myocardial wall thickness; III, maximum left atrium anteroposterior diameter; IV, maximum transverse cardiac diameter; V, myocardial wall thickness; I-IV divided by maximum medial thoracic diameter; and I-IV divided by anteroposterior thoracic diameter. All parameters were measured on axial images: diameters were maximized. ResultsLV systolic dysfunction was indicated when parameter IV exceeded 131.2 mm with sensitivity and specificity of 71.8% and 77.0%, respectively. Moreover, LV diastolic dysfunction was indicated when parameter III divided by anteroposterior thoracic diameter exceeded 0.165 with sensitivity and specificity of 77.8% and 83.0%, respectively. ConclusionsAxial non-contrast chest CT is useful for detecting LV dysfunction. Even CT scans for other purposes provide LV function information that may lead to appropriate examination.

Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis.

Purpose: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. Patients and methods: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital “Fondazione Casa Sollievo della Sofferenza” of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3–8 MHz). For pleural effusions with a depth of 2–3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). Results: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a “safe” quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light’s criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. Conclusions: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.

Can high-frequency transthoracic sonography play a competitive role with high-resolution computed tomography in the assessment of dyspnea?

Background Transthoracic ultrasound (TUS) can potentially give important complementary information in particular conditions like bedside rapid diagnostic evaluation of dyspneic patients who commonly present to emergency (ER) units. Objective Assessing the significance and diagnostic utility of B-lines and pleural line abnormalities detected on TUS among patients presented to the ER unit for the assessment of dyspnea against high-resolution computed tomography findings. Patients and methods A prospective observational study including 240 consecutive patients was conducted. TUS was done for patients presenting to the ER for the assessment of dyspnea. B-lines and the pleural line were evaluated by a linear and convex transducers. Sonographic findings were reported against high-resolution computed tomography findings, which was considered the gold standard. Results Slightly rough, fringed, irregular, interrupted, wavy, coexistence of more than one abnormal type of pleural line were detected in 30.8%, 35.4%, 19.2%, 17.9%, and 30% of cases, respectively. Warrick score classified patients with interstitial lung disease to mild (44.6%), moderate (36.3%), and severe (19.2%). Diffusing capacity for carbon monoxide (DLCO% predicted) and total lung capacity (TLC% predicted) predicted showed negative correlation with Warrick score (r=−0.66, r=−0.48 respectively, P≤0.001 for both) and positive correlation with distance between B lines (r=0.31 and 0.30 respectively, P≤0.001 for both). Warrick score at a cutoff more than 7 showed 96.3% sensitivity and 64.3% specificity. Distance between B lines at cutoff more than 3 mm had 100% sensitivity and 40.4% specificity. Cutoff more than 3 for B lines number/scan showed 92.6% sensitivity and 31% specificity. Pleural thickness at cutoff more than 2 mm showed 100% sensitivity and 34% specificity. Abolished lung sliding showed 96.3% sensitivity and 50% specificity. Conclusion TUS is an important tool for the diagnosis and assessment of pulmonary disorders. B-lines number and distance, pleural line abnormalities, lung sliding, and pleural thickness added diagnostic value for the ER assessment of dyspneic patients.

Evaluation the Frequency of Atelectasis by Transthoracic Lung Ultrasound in Patients Undergoing Laparoscopic Bariatric Surgery Under General Anesthesia

Evaluation the Frequency of Atelectasis by Transthoracic Lung Ultrasound in Patients Undergoing Laparoscopic Bariatric Surgery Under General Anesthesia

Left atrial dynamics and congestion status analysis in acute decompensated heart failure based on LVEF categorization

Abstract Background Left atrial (LA) dynamics play a key role in the hemodynamics assessment of heart failure (HF). LA strain analysis by speckle tracking echocardiography (STE) has recently been introduced in clinical practice. In acute decompensated heart failure (ADHF), LA functional deterioration leads to worsening of pulmonary capillary hypertension and congestion, ultimately impacting prognosis. However, how LA size and function behaves in ADHF according to the different HF phenotypes has never been studied. Purpose To evaluate the diverse morphology and dynamics of the LA, along with a thorough congestion analysis, in ADHF patients with HFpEF, HFmrEF and HFrEF. Methods Eighty-five ADHF patients (mean age 75.6±10.4 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department. In the acute phase all patients underwent a complete transthoracic echocardiography (TTE) and lung ultrasonography (LUS) associated with blood sample and a thorough clinical examination. LA mechanics was assessed with STE, through the evaluation of global peak atrial longitudinal strain (GPALS). Results Out of 85 patients, 51% were classified as HFrEF, 20% as HFmrEF and 29% as HFpEF. At admission, all patients exhibited a comparable degree of congestion, as testified by increased IVC max. diameter (HFpEF 19±7 mm vs HFrEF 20±6.3 mm vs HFmrEF 17±5.3 mm, p=0.167), incremented PASP (HFpEF 39.2±13.5 mmHg vs HFrEF 42±12 mmHg vs HFmrEF 35.3±10.1 mmHg, p=0.15) and a rising number of B-lines on LUS (HFpEF 20±12.8 vs HFrEF 24±17 vs HFmrEF 21±19, p=0.62). Increased NT-proBNP values in the cohort were also noted, with HFrEF exhibiting the highest levels (HFrEF 11747±1069 ng/l vs HFmrEF 6905±811 ng/l vs HFpEF 3918±374 ng/l; p&amp;lt;0.001). When evaluating LA size and dynamics in the different HF phenotypes (HFrEF, HFmrEF and HFpEF respectively) a significant difference among the three subgroups was noted with HFrEF patients exhibiting a greater LA dilation and a higher impairment in terms of LA reservoir function (lowest GPALS/LAVi ratio) compared to HFpEF patients, who showed relatively less enlarged LA chambers and more preserved dynamics. Interestingly, HFmrEF patients expressed the best coupling between LA function and dimension, with significantly reduced LA dimensions and a more preserved LA function compared to HFrEF and HFpEF (LAVi: HFpEF 50.7±16 ml/m2 vs HFrEF 53.9±15 ml/m2 vs HFmrEF 42.8±10.8 ml/m2, p=0.05*; GPALS HFpEF 17±9.1% vs HFrEF 10±4.85% vs HFmrEF 18.3±6.2%, p&amp;lt;0.001*) (Figure 1 and 2). Conclusions ADHF patients exhibit an heterogeneous response in terms of LA size and function according to LVEF categorization. The definition of subjects expressing the worst coupling between LA size and function appears of relevance in order to facilitate risk stratification and identify patients at higher risk of early re-hospitalization. Funding Acknowledgement Type of funding sources: None.

Stroke volume but not ejection fraction predicts prognosis in acute heart failure

Abstract Background Heart failure (HF) patients are categorized according to left ventricular ejection fraction (LVEF), being such index both easily feasible and prognostic. However, the risk stratification of patients hospitalized for acute decompensated heart failure (ADHF) according to the absolute value of LVEF at presentation is unexplored and its prognostic significance has not been tested against stroke volume indexed (SVi). Purpose To examine the prognostic impact of SVi versus LVEF in patients hospitalized for ADHF (wet and warm phenotype). Methods Eighty-five ADHF patients (mean age 75.6±10.4 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department. In the acute phase all patients underwent a complete transthoracic echocardiography (TTE) and lung ultrasonography (LUS) associated with blood sample and a thorough clinical examination. Patients were then stratified into two groups according to the presence or the absence of a preserved SVi at admission (SVi ≥35 ml/m2). Results During a median follow-up (FU) time of 12 months (IQR months 8–15 months) we observed a CV event rate of 28.2%. During the FU period 14 patients (16.5%) were re-hospitalized for ADHF, 7 patients died for CV reason (8.2%), 1 patient underwent mitral valve replacement for severe chronic mitral regurgitation, 1 patient was re-hospitalized for cardiac resynchronization therapy and 1 subject was re-hospitalized for acute coronary syndrome. Interestingly, patients that had a preserved TTE-derived SVi at admission (SVi ≥35 ml/m2) exhibited a significantly higher survival, when compared to subjects that showed an impairment of cardiac output at rest (SVi &amp;lt;35 ml/m2) (log-rank: HR 5.5 CI 95% 2.1–14.3; p=0.04) (Figure 1). On the other hand, LVEF was not independently associated with the endpoint and HFrEF, HFmrEF and HFpEF patients showed a comparable median survival (Figure 2). Conclusions Although the categorization of LVEF in CHF patients bears a pivotal classificatory and prognostic role, its assessment in ADHF, may lack of prognostic value especially when compared to SVi which represents a better parameter to define high-risk subjects who benefit from closer monitoring. Funding Acknowledgement Type of funding sources: None.

Intraoperative Lung Ultrasound (ILU) for the Assessment of Pulmonary Nodules.

Background: The primary aim of this study was to confirm the validity of intraoperative lung ultrasound (ILU) as a safe and effective method of localization for difficult to visualize pulmonary nodules during Video-Assisted Thoracoscopic Surgery (VATS) and open thoracotomy. The secondary aim was to enhance knowledge on the morphological patterns of presentation of pulmonary nodules on direct ultrasound examination. Materials and methods: 131 patients with lung nodule and indication for surgery were enrolled. All patients underwent pre-operative imaging of the chest, including Chest Computed Tomography (CT) and Transthoracic Ultrasound (TUS), and surgical procedures for histological assessment of pulmonary nodules (VATS or open thoracotomy). Results: The identification of 100.00% of lung nodules was allowed by ILU, while the detection rate of digital palpation was 94.66%. It was not possible to associate any specific ILU echostructural pattern to both benign or malignant lesions. However, the actual histological margins of the lesions in the operating samples were corresponding to those visualized at ILU in 125/131 (95.42%) cases. No complications have been reported with ILU employment. Conclusions: In our experience, ILU performed during both open surgery and VATS demonstrated to be a reliable and safe method for visualization and localization of pulmonary nodules non previously assessed on digital palpation. In addition, ILU showed to allow a clear nodule’s margins’ definition matching, in most cases, with the actual histological margins.