Ultrasonographic assessment of pulmonary and Central venous congestion in experimental heart failure.

Pulmonary and systemic congestion as a consequence of heart failure are clinically recognized as alarm signals for clinical outcome and mortality. Although signs and symptoms of congestion are well detectable in patients, monitoring of congestion in small animals with heart failure lacks adequate noninvasive methodology yet. Here, we developed a novel ultrasonography-based scoring system to assess pulmonary and systemic congestion in experimental heart failure, by using lung ultrasound (LUS) and imaging of the inferior vena cava (Cava), termed CavaLUS. CavaLUS was established and tested in a rat model of supracoronary aortic banding and a mouse model of myocardial infarction, providing high sensitivity and specificity while correlating to numerous parameters of cardiac performance and disease severity. CavaLUS, therefore, provides a novel comprehensive tool for experimental heart failure in small animals to noninvasively assess congestion.NEW & NOTEWORTHY As thorough, noninvasive assessment of congestion is not available in small animals, we developed and validated an ultrasonography-based research tool to evaluate pulmonary and central venous congestion in experimental heart failure models.

Utility of nicardipine in the management of hypertensive crises in adults with reduced ejection fractions.

BACKGROUND: Nicardipine is commonly used in the management of hypertensive crises, except those involving cardiac contractility defects despite its ability to reduce afterload and pulmonary congestion. Consequently, there is limited literature evaluating nicardipine's role for this indication. The purpose of this study was to evaluate the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting with acute heart failure with hypertension (AHF-H). METHODS: This was a retrospective study conducted at an academic Level 1 trauma center with an annual Emergency Department (ED) volume surpassing 100,000. The purpose of this study was to determine the efficacy and safety of nicardipine in adults with reduced ejection fractions presenting to the ED with AHF-H. Efficacy was determined by achievement of the physician prescribed blood pressure target range. The primary safety endpoints included the number of individuals who experienced bradycardia (< 60 beats per minute, bpm) or hypotension (systolic blood pressure, SBP, < 90 mmHg) while receiving nicardipine and for up to 15 min after its discontinuation. Patients were included if they were ≥ 18 years of age, received a continuous intravenous nicardipine infusion within six hours of presenting to the ED, and had an ejection fraction ≤ 40% per an echocardiogram obtained within three months of the study visit. Pregnant and incarcerated patients were excluded. RESULTS: Of the 500 patient charts reviewed, 38 met inclusion criteria. The median (interquartile, IQR) ejection fraction and brain natriuretic peptide (BNP) were 35% (25-40) and 731 pg/nL (418-3277), respectively. The median baseline heart rate and SBP were 90 bpm and 193 mmHg, respectively. The median physician specified SBP goal was 160 mmHg and all patients met this endpoint in a median time of 18 min. One (2.6%) patient in the total population developed both hypotension and bradycardia. This patient had an ejection fraction of 20%, was intubated, and received nicardipine in addition to esmolol for an aortic dissection without experiencing an adverse event until 30 min after dexmedetomidine was initiated. CONCLUSION: In this non-interventional study evaluating the use of nicardipine in patients with reduced ejection fractions presenting to the ED with AHF-H, nicardipine was found to be safe and effective. To our knowledge this is the largest study to date evaluating nicardipine in this patient population and positively contributes to the existing literature.

Update on the Value of Lung Ultrasound Examination in Acute Decompensated Heart Failure Patients with Various Left Ventricular Ejection Fraction.

Acute decompensated heart failure (ADHF) is one of the most common causes of hospital admission for cardiovascular diseases. ADHF often affects the elderly population, is associated with high morbidity, admission rate and mortality. Pulmonary congestion (PC) is the most common cause of hospitalization among ADHF patients. Previous studies have shown that lung ultrasound (LUS) serves as a valuable tool for the evaluation of PC in patients with heart failure in terms of diagnosis, guiding of the treatment, and post-discharge monitoring. The use of LUS for ADHF is well described and already widely used in the daily clinical practice. PC might differ in ADHF patients with different left ventricular ejection fraction value and treatment options should be steadily adjusted according to the LUS-derived PC results to improve the outcome. This review summarized the value of LUS examination in patients with ADHF with preserved, mildly reduced, and reduced left ventricular ejection fraction, aiming to expand the rational use of LUS, promote the LUS-guided management and improve the outcome among patients with ADHF.

Pulmonary congestion and systemic congestion in hemodialysis: dynamics and correlations.

Introduction: Systemic congestion and pulmonary congestion (PC) are common in hemodialysis (HD) patients. However, the relationship between these two entities is not quite clear. We study this relationship and attempt to uncover the factors that may affect it considering different inter-dialytic intervals. Methods: A prospective pilot observational and interventional study including 18 HD patients was conducted. The following were obtained: i) B-line score (BLS) by lung ultrasound (LUS) (reflecting significant pulmonary congestion if BLS > 5), ii) echocardiography, iii) bioelectrical impedance analysis (BIA) (reflecting global volume status), and iv) inferior vena cava (IVC) dynamics (reflecting systemic congestion) before and after the first two consecutive HD sessions of the week, with different inter-dialytic intervals (68 hours and 44 hours). Serum N-terminal pro-brain natriuretic peptide type B (NT-proBNP) levels were obtained before each session. Then, patients were randomized into two groups: the active group, where dry weight was reduced according to BLS + standard of care, and the control group, where dry weight was modified according to standard of care. All the measures were repeated on day 30. Results: We found no correlation between pulmonary congestion represented by BLS and IVC dimensions and dynamics reflecting systemic congestion, independent of different inter-dialytic intervals. Pulmonary congestion was quite prevalent, as mean pre- and post-dialysis BLSs were quite elevated (16 ± 5.53 and 15.3 ± 6.63, respectively) in the first session compared with the second session (16.3 ± 5.26 and 13.6 ± 5.83, respectively). Systolic (left ventricular ejection fraction) and diastolic cardiac function (e/è ratio) parameters from one side and pulmonary congestion (BLS) from the other were not always correlated. BLS was correlated to e/è ratio before HD (session 1) (R 2 = 0.476, p = 0.002) and after HD (session 2) (R 2 = 0.193, p = 0.034). Pulmonary congestion reflected by BLS was correlated to the global volume state reflected by BIA only in the second HD session (HD2) (R 2 = 0.374, p = 0.007). NT-proBNP levels and BLS were correlated before both sessions (R 2 = 0.421, p = 0.004, and R 2 = 0.505, p = 0.001, respectively). Systemic congestion was quite prevalent, as mean pre- and post-dialysis IVC dimensions and dynamics were quite elevated in both sessions, with a higher level of systemic congestion in the first HD session (diameter and collapsibility of 2.1 cm and 23%, and 2.01 cm and 19%, respectively) compared with the second session (1.98 cm and 17.5%, and 1.9 cm and 22%, respectively) without reaching statistical significance. IVC dimensions and global volume status measured by BIA were correlated in the second dialysis session (R 2 = 0.260, p = 0.031). No correlation was found between IVC dimensions and diastolic cardiac function (e/è ratio) parameters or with NT-proBNP levels. On day 30, BLS was significantly reduced in the active group, whereas no difference was found in the control group. However, no real impact was observed on IVC dimensions and dynamics or in total volume status by BIA. Conclusion: Pulmonary congestion is common in HD patients even after reaching their dry weight at the end of two consecutive sessions, and it is not correlated to systemic congestion, suggesting a complex multifactorial pathophysiology origin. Global volume status reflected by BIA and cardiac function are not always related to either systemic congestion represented by IVC dimensions or pulmonary congestion represented by BLS. Fluid redistribution anomalies may allow pulmonary congestion accumulation independently from systemic congestion and global volume status (non-cardiogenic pulmonary congestion). We recommend a personalised approach when managing HD patients by integrating systemic and pulmonary congestion parameters. Dry weight modification guided by repeat LUS may safely reduce pulmonary congestion. However, no impact was observed on systemic congestion or global volume status.

Computed tomography or chest X-ray to assess pulmonary congestion in dyspnoeic patients with acute heart failure.

AIMS: While computed tomography (CT) is widely acknowledged as superior to chest radiographs for acute diagnostics, its efficacy in diagnosing acute heart failure (AHF) remains unexplored. This prospective study included consecutive patients with dyspnoea undergoing simultaneous low-dose chest CT (LDCT) and chest radiographs. Here, we aimed to determine if LDCT is superior to chest radiographs to confirm pulmonary congestion in dyspnoeic patients with suspected AHF. METHODS AND RESULTS: An observational, prospective study, including dyspnoeic patients from the emergency department. All patients underwent concurrent clinical examination, laboratory tests, echocardiogram, chest radiographs, and LDCT. The primary efficacy measure to compare the two radiological methods was conditional odds ratio (cOR). The primary outcome was adjudicated AHF, ascertained by comprehensive expert consensus. The secondary outcome, echo-bnp AHF, was an objective AHF diagnosis based on echocardiographic cardiac dysfunction, elevated cardiac filling pressure, loop diuretic administration, and NT-pro brain natriuretic peptide > 300 pg/mL. Of 228 dyspnoeic patients, 64 patients (28%) had adjudicated AHF, and 79 patients (35%) had echo-bnp AHF. Patients with AHF were older (78 years vs. 73 years), had lower left ventricular ejection fraction (36% vs. 55%), had higher elevated left ventricular filling pressures (98% vs. 18%), and had higher NT-pro brain natriuretic peptide levels (3628 pg/mL vs. 470 pg/mL). The odds to diagnose adjudicated AHF and echo-bnp AHF were up to four times greater using LDCT (cOR: 3.89 [2.15, 7.06] and cOR: 2.52 [1.45, 4.38], respectively). For each radiologic sign of pulmonary congestion, the LDCT provided superior or equivalent results as the chest radiographs, and the interrater agreement was higher using LDCT (kappa 0.88 [95% CI: 0.81, 0.95] vs. 0.73 [95% CI: 0.63, 0.82]). As first-line imaging modality, LDCT will find one additional adjudicated AHF in 12.5 patients and prevent one false-positive in 20 patients. Similar results were demonstrated for echo-bnp AHF. CONCLUSIONS: In consecutive dyspnoeic patients admitted to the emergency department, LDCT is significantly better than chest radiographs in detecting pulmonary congestion.

Experience with the Kosmos ultrasonographic tool in the approach and treatment of ambulatory patients of a heart failure clinic: a single-center cross-sectional study.

BACKGROUND: In Mexico, the epidemiology of heart failure is still not well understood. However, it is known that the primary cause of hospital admissions in patients with heart failure is pulmonary and systemic congestion. OBJECTIVE: To estimate congestion status and assess cardiac function using portable ultrasound in patients with heart failure. METHOD: A cross-sectional observational study was conducted. Patients who attended the Heart Failure Clinic at the Ignacio Chávez National Cardiology Institute in Mexico City between May and August 2022 were selected. They underwent ultrasonographic evaluation using a portable device to assess pulmonary and systemic congestion, as well as cardiac function and structure. RESULTS: One-hundred patients diagnosed with heart failure were prospectively included during the study period; 76% were male, with an average age of 59 years (range: 50-68 years). The recorded LVEF median was 34% (IQR: 27-43.5%). When evaluating pulmonary congestion, 78% of the patients showed a pattern A and 22% a pattern B. Following the VExUS protocol, 92% of the patients were at grade 0, 2% at grade 1, and 6% at grade 2. CONCLUSIONS: The use of the portable ultrasound facilitated the quantitative characterization of the echocardiographic features of the studied population. This device could provide better clinical characterization which, in turn, might allow for optimized drug prescription for heart failure and dose adjustments of diuretics based on echocardiographic congestion findings.

ANTECEDENTES: En México aún es muy poco conocida la epidemiología de la insuficiencia cardiaca, sin embargo se sabe que la principal causa de ingresos hospitalarios en los pacientes con insuficiencia cardiaca es la congestión pulmonar y sistémica. OBJETIVO: Estimar el estado de congestión y evaluar la función cardiaca mediante el ultrasonido portátil en pacientes con insuficiencia cardiaca tratados en un centro de tercer nivel en México. MÉTODO: Se llevó a cabo un estudio observacional transversal. Se seleccionaron pacientes que acudieron a la Clínica de Insuficiencia Cardiaca del Instituto Nacional de Cardiología Ignacio Chávez en la Ciudad de México entre mayo y agosto de 2022. Se les sometió a una evaluación ultrasonográfica mediante un dispositivo portátil para valorar la congestión pulmonar y sistémica, así como la función y estructura cardiaca. RESULTADOS: Se incluyeron de forma prospectiva 100 pacientes diagnosticados con insuficiencia cardiaca en el periodo de estudio. El 76% fueron hombres, con una edad mediana de 59 años (RIQ: 50-68 años). La mediana del FEVI registrada fue del 34% (RIQ: 27.0-43.5%). Al evaluar la congestión pulmonar, el 78% de los pacientes presentaron un patrón A y el 22% un patrón B. Siguiendo el protocolo VExUS, el 92% de los pacientes mostraron un grado 0, el 2% un grado 1 y el 6% un grado 2. CONCLUSIONES: El uso del ultrasonido portátil facilitó la caracterización cuantitativa de las características ecocardiográficas de la población estudiada. Este dispositivo podría ofrecer una mejor caracterización clínica que, a su vez, permita una optimización en la prescripción de medicamentos para la insuficiencia cardiaca y el ajuste de dosis de diuréticos según los hallazgos ecocardiográficos de congestión.

Pulmonary congestion assessed by lung ultrasound in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: Prevalence and prognostic implications.

AIMS: Lung ultrasound (LUS) is a sensitive tool to assess pulmonary congestion (PC). Few data are available on LUS-PC evaluation in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the prevalence and prognostic impact of LUS-PC in patients with severe AS before and after TAVI. METHODS AND RESULTS: We designed a single-centre prospective study in patients referred for TAVI for severe AS (ClinicalTrials.gov identification number: NCT05024942). All patients underwent echocardiography and LUS (according to a simplified 8-zone scanning protocol) the day before and within 72 h after the procedure. The primary endpoint was the composite of all-cause mortality, hospitalization for heart failure and urgent medical visits for worsening dyspnoea at 12-month follow-up. A total of 127 patients were enrolled (mean age 81.1 ± 5.8 years; 54.3% female). Pre-TAVI LUS-PC was documented in 65 patients (51%). After TAVI, the prevalence of LUS-PC significantly decreased as compared to pre-TAVI evaluation, being documented in only 28 patients (22% vs. 51%, p < 0.001) with a median B-lines score of 4 (interquartile range [IQR] 0-11) versus 11 (IQR 6-19) pre-TAVI (p < 0.001). During a median follow-up of 12 (12-17) months, 25 patients (19.6%) met the composite endpoint. On multivariable Cox regression analysis, pre-TAVI LUS-PC was independently associated with cardiovascular events (hazard ratio 2.764, 95% confidence interval 1.114-6.857; p = 0.028). CONCLUSIONS: Lung ultrasonography reveals a high prevalence of PC in patients with severe AS undergoing TAVI, which is significantly reduced by the procedure. Pre-TAVI PC, measured by LUS, is an independent predictor of 1-year clinical outcome.

Right heart failure as a cause of pulmonary congestion in pulmonary arterial hypertension.

AIMS: Recent studies have shown that lung ultrasound-assessed pulmonary congestion is worse in heart failure when pulmonary vascular resistance (PVR) is increased, suggesting a paradoxical relationship between right heart failure and increased lung water content. Accordingly, we wondered if lung ultrasound would reveal otherwise clinically silent pulmonary congestion in patients with pulmonary arterial hypertension (PAH). METHODS AND RESULTS: All patients referred for suspicion of PAH in a tertiary centre from January 2020 to December 2022 underwent a complete diagnostic work-up including echocardiography, lung ultrasound and right heart catheterization. Pulmonary congestion was identified by lung ultrasound B-lines using an 8-site scan. The study enrolled 102 patients with idiopathic PAH (mean age 53 ± 13 years; 71% female). World Health Organization functional classes I, II, and III were found in 2%, 52%, and 46% of them, respectively. N-terminal pro-brain natriuretic peptide (NT-proBNP) was 377 pg/ml (interquartile range [IQR] 218-906). B-lines were identified in 77 out of 102 patients (75%), with a median of 3 [IQR 1-5]. At univariable analysis, B-lines were positively correlated with male sex, age, NT-proBNP, systolic pulmonary artery pressure (sPAP), right atrial pressure (RAP), PVR, left ventricular end-diastolic volume and tricuspid annular plane systolic excursion (TAPSE), and negatively with cardiac output and stroke volume. At multivariable analysis, RAP (p < 0.001), TAPSE/sPAP (p = 0.001), and NT-proBNP (p = 0.04) were independent predictors of B-lines. CONCLUSION: Lung ultrasound commonly discloses pulmonary congestion in PAH. This finding is related to right ventricular to pulmonary artery uncoupling, and may tentatively be explained by increased central venous pressure impeding lymphatic outflow.

Systematic implementation of cardiopulmonary ultrasound imaging to optimize management of acute decompensated heart failure.

BACKGROUND: Heart failure (HF) poses a major health problem, where frequent HF rehospitalizations (HFH) heavily burden national health systems. HFH are predominantly linked to inadequate decongestion before discharge. It is uncertain if systematic implementation of cardio-pulmonary ultra-sound imaging (CPUSI) to standard HF management can improve outcomes and reduce HFH. RESULTS: This study recruited 50 patients admitted with acute decompensated heart failure (ADHF). Besides the conventional daily assessment, CPUSI was systematically performed to guide treatment decisions, focusing on ventricular filling pressure and 8-zone lung ultrasound (LUS) score. On-admission and predischarge LUS scores were correlated to clinical outcomes. The mean age of the study group was 55.7 ± 10.59 years, with predominance of male gender. Supplementing clinical judgment, CPUSI modified therapeutic strategy in 57 out of 241 assessments (24%), improving patients' care. Besides its value in guiding therapeutic decisions, the LUS score on admission had a significant positive correlation to the length of ICU stay and the total hospitalization length. Also, LUS score > 12 at discharge predicted 90-day HFH with sensitivity and specificity of 100% and 98%, respectively. CONCLUSIONS: Systematic CPUSI can improve HF management by complementing the often challenging judgment of pulmonary congestion. Adding periodic evaluation of ventricular filling pressures and LUS scores to clinical assessment can optimize treatment decisions and improve patient care. LUS score was a significant predictor for in-hospital and post-discharge clinical outcomes.

Natriuretic Peptides and Need for Reliable Tool to Assess Pulmonary Congestion for Treatment Monitoring in Heart Failure.

Natriuretic peptides (NPs) play a significant role in the pathophysiology of heart failure (HF) and are considered reliable diagnostic and prognostic indicators of congestive HF. Pulmonary congestion in HF patients leads to clinical deterioration and hospitalizations. It remains an important aspect to address the management and treatment tailoring in HF patients. However, the role of NP-guided therapy remains debatable due to contrasting reports in the literature. Current guidelines do not recommend the use of NP-guided therapy in the treatment monitoring of HF. Therefore, there is an urgent need to identify reliable markers for treatment monitoring in congestive HF. For early detection of congestion, a technology-based approach to monitor pulmonary hemodynamics and absolute lung fluid measurement is found to be effective in guiding treatment. Remote dielectric sensing technology is one such non-invasive approach that measures pulmonary fluid levels in the lungs which results in reduced hospitalization and re-admission rate in HF patients. In this review, we summarized the role of natriuretic peptides and the need for a reliable tool to assess pulmonary congestion for treatment monitoring in HF.

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

Background: In 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. Objective: To evaluate performance of LUS for congestion screening in advanced HF referred for transplant, as compared to findings of right heart catheterization (RHC). Methods: Prospective 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. Results: Congestion 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). Conclusions: In 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.

Experiencia con la herramienta ultrasonográfica Kosmos en el abordaje y tratamiento de pacientes de la consulta externa de insuficiencia cardiaca: un estudio transversal unicéntrico / Experience with the Kosmos ultrasonographic tool in the approach and treatment of ambulatory patients of a heart failure clinic: a single-center cross-sectional study

Resumen Antecedentes: En México aún es muy poco conocida la epidemiología de la insuficiencia cardiaca, sin embargo se sabe que la principal causa de ingresos hospitalarios en los pacientes con insuficiencia cardiaca es la congestión pulmonar y sistémica. Objetivo: Estimar el estado de congestión y evaluar la función cardiaca mediante el ultrasonido portátil en pacientes con insuficiencia cardiaca tratados en un centro de tercer nivel en México. Método: Se llevó a cabo un estudio observacional transversal. Se seleccionaron pacientes que acudieron a la Clínica de Insuficiencia Cardiaca del Instituto Nacional de Cardiología Ignacio Chávez en la Ciudad de México entre mayo y agosto de 2022. Se les sometió a una evaluación ultrasonográfica mediante un dispositivo portátil para valorar la congestión pulmonar y sistémica, así como la función y estructura cardiaca. Resultados: Se incluyeron de forma prospectiva 100 pacientes diagnosticados con insuficiencia cardiaca en el periodo de estudio. El 76% fueron hombres, con una edad mediana de 59 años (RIQ: 50-68 años). La mediana del FEVI registrada fue del 34% (RIQ: 27.0-43.5%). Al evaluar la congestión pulmonar, el 78% de los pacientes presentaron un patrón A y el 22% un patrón B. Siguiendo el protocolo VExUS, el 92% de los pacientes mostraron un grado 0, el 2% un grado 1 y el 6% un grado 2. Conclusiones: El uso del ultrasonido portátil facilitó la caracterización cuantitativa de las características ecocardiográficas de la población estudiada. Este dispositivo podría ofrecer una mejor caracterización clínica que, a su vez, permita una optimización en la prescripción de medicamentos para la insuficiencia cardiaca y el ajuste de dosis de diuréticos según los hallazgos ecocardiográficos de congestión.

Abstract Background: In Mexico, the epidemiology of heart failure is still not well understood. However, it is known that the primary cause of hospital admissions in patients with heart failure is pulmonary and systemic congestion. Objective: To estimate congestion status and assess cardiac function using portable ultrasound in patients with heart failure. Method: A cross-sectional observational study was conducted. Patients who attended the Heart Failure Clinic at the Ignacio Chávez National Cardiology Institute in Mexico City between May and August 2022 were selected. They underwent ultrasonographic evaluation using a portable device to assess pulmonary and systemic congestion, as well as cardiac function and structure. Results: One-hundred patients diagnosed with heart failure were prospectively included during the study period; 76% were male, with an average age of 59 years (range: 50-68 years). The recorded LVEF median was 34% (IQR: 27-43.5%). When evaluating pulmonary congestion, 78% of the patients showed a pattern A and 22% a pattern B. Following the VExUS protocol, 92% of the patients were at grade 0, 2% at grade 1, and 6% at grade 2. Conclusions: The use of the portable ultrasound facilitated the quantitative characterization of the echocardiographic features of the studied population. This device could provide better clinical characterization which, in turn, might allow for optimized drug prescription for heart failure and dose adjustments of diuretics based on echocardiographic congestion findings.

Pulmonary Ultrasound in Patients with Heart Failure - Systematic Review / Ultrassom Pulmonar em Pacientes com Insuficiência Cardíaca - Revisão Sistemática

Abstract Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied.

Resumo A congestão pulmonar é um achado clínico importante em paciente com insuficiência cardíaca (IC). Exame físico e radiografia do tórax têm acurácia limitada na detecção da congestão. A ultrassonografia pulmonar (UP) vem sendo incorporada à prática clínica na avaliação da congestão pulmonar. Este artigo teve como objetivo realizar revisão sistemática sobre a utilização da UP em pacientes com IC, nos diferentes cenários. Foi realizada uma pesquisa nas bases de dados MEDLINE e LILACS no mês de fevereiro de 2017 envolvendo artigos publicados entre 2006 e 2016. Foram encontrados 26 artigos na presente revisão, 11 deles no cenário da emergência e 7 em cenário ambulatorial, com valor diagnóstico e prognóstico definido e valor terapêutico pouco estudado. A UP aumentou a acurácia em 90% em relação ao exame físico e à radiografia do tórax para o diagnóstico da congestão, sendo mais sensível e precoce. A qualificação do executor da UP não interferiu na acurácia diagnóstica. O achado de linhas B ≥ 15 teve correlação com BNP elevado (≥ 500) e relação E/e' ≥ 15, com impacto prognóstico em pacientes com IC ambulatoriais e na alta hospitalar. Conclui-se que, na avaliação da congestão pulmonar na IC, a UP tem valor incremental na abordagem diagnóstica e prognóstica em todos os cenários encontrados.

Echocardiographic parameters associated with pulmonary congestion in outpatients with Chagas' cardiomyopathy and non-chagasic cardiomyopathy / Parâmetros ecocardiográficos associados com a congestão pulmonar nas miocardiopatias chagásica e não-chagásica

INTRODUCTION: Despite significant left ventricular (LV) systolic dysfunction and cardiomegaly, pulmonary congestion does not seem to be a major finding in Chagas' cardiomyopathy (CC). This study sought to identify echocardiographic parameters associated with pulmonary congestion in CC and in dilated cardiomyopathy of other etiologies, such as non-CC (NCC), and to compare pulmonary venous hypertension between the two entities. METHODS: A total of 130 consecutive patients with CC and NCC, with similar echocardiographic characteristics, were assessed using Doppler echocardiography and chest radiography. Pulmonary venous vessel abnormalities were graded using a previously described pulmonary congestion score, and this score was compared with Doppler echocardiographic parameters. RESULTS: NCC patients were older than CC patients (62.4 ± 13.5 × 47.8 ± 11.2, p = 0.00), and there were more male subjects in the CC group (66.2% × 58.5%, p = 0.4). Pulmonary venous hypertension was present in 41 patients in the CC group (63.1%) and in 63 (96.9%) in the NCC group (p = 0.0), the mean lung congestion score being 3.2 ± 2.3 and 5.9 ± 2.6 (p = 0.0), respectively. On linear regression multivariate analysis, the E/e' ratio (β = 0.13; p = 0.0), LV diastolic diameter (β = 0.06; p = 0.06), left atrial diameter (β = 0.51; p = 0.08), and right ventricular (RV) end-diastolic diameter (β = 0.02; p = 0.48) were the variables that correlated with pulmonary congestion in both groups. CONCLUSIONS: Pulmonary congestion was less significant in patients with CC. The degree of LV of systolic and diastolic dysfunction and the RV diameter correlated with pulmonary congestion in both groups. The E/e' ratio was the hallmark of pulmonary congestion in both groups.

INTRODUÇÃO: Na miocardiopatia chagásica, ocorre uma discrepância entre os achados de disfunção ventricular e uma menor magnitude de congestão pulmonar em relação a outras miocardiopatias. Foram associados parâmetros morfofuncionais ecocardiográficos com achados de congestão pulmonar à radiografia do tórax em pacientes portadores de miocardiopatia chagásica e não chagásica, sendo a intensidade dos achados radiológicos comparada nos dois grupos. MÉTODOS: Foram recrutados 130 pacientes portadores de miocardiopatia chagásica e não chagásica, tendo os dois grupos parâmetros ecocardiográficos semelhantes. Todos realizaram o estudo radiológico do tórax, sendo atribuída uma pontuação aos achados sugestivos de congestão pulmonar, conforme escore já previamente estabelecido, sendo este comparado com os achados ecocardiográficos de disfunção ventricular. RESULTADOS: Os pacientes não chagásicos eram mais idosos (62,4±13,5 x 47,8±11,2, p=0,0), havendo um predomínio do sexo feminino nos chagásicos (66,2% x 58,5%, p=0,4). A hipertensão venocapilar pulmonar esteve presente em 41 chagásicos (63,1%) e 63 (96,9%) não-chagásicos (p=0,0), com escore da congestão pulmonar de 3,2±2,3 e 5,9±2,6 (p=0,0) respectivamente. Na análise de regressão linear, a relação E/e' (β=0,13; p=0,0), o diâmetro diastólico do ventrículo esquerdo (β=0,06; p=0,06), o diâmetro do átrio esquerdo (β=0,51; p=0,08) e o diâmetro diastólico final do ventrículo direito (β=0,02; p=0,48) foram as variáveis que mais se associaram com a congestão pulmonar nos dois grupos. CONCLUSÕES: Os pacientes chagásicos apresentaram um menor grau de congestão pulmonar. Os parâmetros de disfunção sistólica e diastólica associaram com a intensidade da congestão pulmonar, sendo a relação E/e' a variável que mais determinou a congestão pulmonar nos dois grupos.

Echocardiographic parameters associated with pulmonary congestion in Chagas cardiomyopathy / Parâmetros ecocardiográficos associados com a congestão pulmonar na miocardiopatia chagásica

INTRODUCTION: Discrepancy between the intensity of pulmonary congestion and the grade of cardiomegaly seems to be a common finding of Chagas cardiomyopathy, in spite of significant systolic dysfunction of the left ventricle. Its mechanism has not been established. The aim of this study was to investigate pulmonary congestion and to analyze if it correlated with Doppler echocardiographic parameters in patients with Chagas dilated cardiomyopathy. METHODS: Fifty-five patients with positive serology tests for Trypanosoma cruzi and Chagas dilated cardiomyopathy were studied. Chest x-rays, Doppler echocardiogram and plasmatic brain natriuretic peptide levels were obtained in all patients. The degree of pulmonary venous vessels changes on chest x-ray was graded using a pulmonary congestion score, and then compared to Doppler echocardiographic parameters. RESULTS: Mean age was 48.5 ± 11.2 years and 29 percent were women. The majority (95 percent) of patients were in NYHA functional class I and II. Mild pulmonary congestion by chest x-ray was found in 80 percent of the patients. In a multivariate analysis, left ventricular ejection fraction, right ventricular TEI index and the color M-mode velocity correlated with the degree of pulmonary congestion. CONCLUSIONS: Pulmonary venous changes on chest x-rays are frequent, but usually mild in patients with Chagas dilated cardiomyopathy. The degree of pulmonary congestion correlates with Doppler echocardiographic left and right ventricular dysfunction and with color M-mode velocity.

INTRODUÇÃO: Na miocardiopatia chagásica, é considerado haver uma menor intensidade de congestão pulmonar, mesmo na vigência de disfunção ventricular esquerda importante, não havendo ainda explicação definitiva para este fenômeno. O objetivo deste estudo foi de investigar a presença de congestão pulmonar na miocardiopatia chagásica e analisar se a intensidade da congestão esteve associada com parâmetros morfofuncionais ecocardiográficos de disfunção cardíaca. MÉTODOS: Cinquenta e cinco pacientes com sorologia positiva para o Trypanosoma cruzi e portadores de miocardiopatia chagásica foram estudados. Todos os pacientes foram submetidos ao estudo radiológico do tórax, ecocardiograma e dosagem plasmática do peptídeo natriurético cerebral. O grau de congestão pulmonar foi quantificado através de um escore da congestão pulmonar, e então comparado com os parâmetros ecocardiográficos. RESULTADOS: A idade média foi de 48.5 ± 1.2 anos e 29 por cento eram mulheres. A maior (95 por cento) parte dos pacientes encontrava-se na classe funcional I e II. Discreta congestão pulmonar à radiografia do tórax foi encontrada em 80 por cento dos pacientes. Na análise multivariada, a fração de ejeção do ventrículo esquerdo, o índice de TEI do ventrículo direito e a velocidade ao color M mode foram as variáveis que mais estiveram associadas com o grau de congestão pulmonar. CONCLUSÕES: Nos pacientes com miocardiopatia chagásica, as alterações do fluxo venoso pulmonar foram frequentes, porém discretas. O grau de congestão pulmonar associou com parâmetros ecocardiográficos de disfunção ventricular esquerda e direita e com a velocidade do color M mode.