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.

Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols.

RATIONALE & OBJECTIVE: Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED: 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME: Prediction of pulmonary congestion and 30-day mortality. RESULTS: All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS: Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS: Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

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.

Prognostic value of B lines detected with lung ultrasound in acute heart failure. A systematic review.

Pulmonary ultrasound is a simple diagnostic tool with immediate results for the assessment of pulmonary congestion in patients with heart failure (HF), allowing optimization of treatment by monitoring the dynamic changes identified. We aimed to evaluate the prognostic significance of the presence of B lines detected by lung ultrasound during hospitalization for heart failure. A search was conducted for scientific articles in PubMed, Embase, Google Scholar, and Cochrane databases including clinical trials, reviews, systematic reviews, and original articles that were related to the prognostic value of lung ultrasound in patients with HF in the last 5 years from 2016 to 2021. Studies including individuals aged ≥18 years evaluating the prognostic value of lung ultrasound in HF were included. Fourteen articles met inclusion criteria for analysis (three reviews, three systematic reviews with meta-analysis, six prospective studies, and two retrospective studies). The presence of more than 30-40 B lines at admission were considered a risk factor for readmission or mortality as was persistent pulmonary congestion with the presence of ≥15 B-lines. The presence of pulmonary congestion detected by lung ultrasound in acute heart failure has prognostic significance in terms of mortality and hospital readmission. Clinical trials are needed to evaluate whether diuretic therapy guided by lung ultrasound and the presence of B lines can reduce readmission and mortality in these patients.

The Degree of the Predischarge Pulmonary Congestion in Patients Hospitalized for Worsening Heart Failure Predicts Readmission and Mortality.

BACKGROUND: Prediction of readmission and death after hospitalization for heart failure (HF) is an unmet need. AIM: We evaluated the ability of clinical parameters, NT-proBNP level and noninvasive lung impedance (LI), to predict time to readmission (TTR) and time to death (TTD). METHODS AND RESULTS: The present study is a post hoc analysis of the IMPEDANCE-HF extended trial comprising 290 patients with LVEF ≤45% and New York Heart Association functional class II-IV, randomized 1:1 to LI-guided or conventional therapy. Of all patients, 206 were admitted 766 times for HF during a follow-up of 57 ± 39 months. The normal LI (NLI), representing the "dry" lung status, was calculated for each patient at study entry. The current degree of pulmonary congestion (PC) compared with its dry status was represented by ΔLIR = ([measured LI/NLI] - 1) × 100%. Twenty-six parameters recorded during HF admission were used to predict TTR and TTD. To determine the parameter which mainly impacted TTR and TTD, variables were standardized, and effect size (ES) was calculated. Multivariate analysis by the Andersen-Gill model demonstrated that ΔLIRadmission (ES = 0.72), ΔLIRdischarge (ES = -3.14), group assignment (ES = 0.2), maximal troponin during HF admission (ES = 0.19), LVEF related to admission (ES = -0.22) and arterial hypertension (ES = 0.12) are independent predictors of TTR (p < 0.01, χ2 = 1,206). Analysis of ES showed that residual PC assessed by ∆LIRdischarge was the most prominent predictor of TTR. One percent improvement in predischarge PC, assessed by ∆LIRdischarge, was associated with a likelihood of TTR increase by 14% (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.13-1.15, p < 0.01) and TTD increase by 8% (HR 1.08, 95% CI 1.07-1.09, p < 0.01). CONCLUSION: The degree of predischarge PC assessed by ∆LIR is the most dominant predictor of TTR and TTD.

Lung ultrasound and BNP to detect hidden pulmonary congestion in euvolemic hemodialysis patients: a single centre experience.

BACKGROUND: Dry weight assessment in hemodialysis (HD) remains a challenge. The aim of the study was to investigate the prevalence of subclinical pulmonary congestion using lung ultrasound (LUS) in maintenance HD patients with no clinical or bioimpedance signs of hyperhydration. The correlation between B-lines Score (BLS) and brain natriuretic peptide (BNP) was also evaluated. METHODS: Twenty-four HD patients underwent LUS and BNP dosage at the end of the mid-week HD session, monthly for 6 months . LUS was considered as positive when BLS was >15. Hospitalizations and cardiovascular events were also evaluated in relation to the BLS. RESULTS: LUS+ patients at baseline were 16 (67%), whereas 11 (46%) showed LUS + in at least 50% of the measurements (rLUS+ patients). Only the rLUS+ patients had a higher number of cardiovascular events [p=0.019, OR: 7.4 (CI 95%. 1.32-39.8)] and hospitalizations [p=0.034, OR 5.5 (CI 95% 1.22- 24.89)]. A BNP level of 165 pg/ml was identified as cut-off value for predicting pulmonary congestion, defined by BLS >15. CONCLUSION: Prevalence of pulmonary congestion as assessed by LUS and persistent or recurrent BLS >15 were quite prevalent findings in euvolemic HD patients. In the patients defined as rLUS+, a higher rate of cardiovascular events and hospital admissions was registered. BNP serum levels > 165 pg/ml resulted predictive of pulmonary congestion at LUS. In the dialysis care, regular LUS examination should be reasonably included among the methods useful to detect subclinical lung congestion and to adjust patients' dry weight.

Effects of exercise on thoracic blood volumes, lung fluid accumulation, and pulmonary diffusing capacity in heart failure with preserved ejection fraction.

Patients with heart failure with preserved ejection fraction (HFpEF) experience symptoms of exertional dyspnea that may be related to lung fluid accumulation during exercise. A computed tomography (CT)-based method was used to measure exercise-induced changes in extravascular lung fluid content and thoracic blood volumes and to determine the effect of lung fluid on lung diffusing capacity for carbon monoxide (DLCO) in stable subjects with HFpEF and healthy controls. Nine subjects with HFpEF (age = 68 ± 8 yr; body mass index = 32.1 ± 2.6 kg/m2) and eight healthy controls (62 ± 9 yr, 23.8 ± 2.4 kg/m2) performed triplicate rebreathe DLCO/DLNO (lung diffusing capacity for nitric oxide) tests in a supine position at rest and duplicate measurements during two 5-min submaximal exercise stages (15W and 35W) and recovery. Subjects subsequently performed a 5-min exercise bout (35W) inside a CT scanner, and extravascular lung fluid content and thoracic blood volumes were quantified at rest and immediately following exercise from thoracic and contrast perfusion scans, respectively. Subjects with HFpEF had a higher lung fluid content at rest compared with controls (means ± SD, HFpEF: 14.4 ± 1.7%, control: 12.8 ± 1.7%, P = 0.043) and a higher lung fluid content following exercise (15.2 ± 2.0% vs. 12.6 ± 1.5%, P = 0.009). Higher lung fluid content was associated with a lower DLCO and alveolar-capillary membrane conductance (Dm) in subjects with HFpEF (DLCO: R = -0.57, P = 0.022, Dm: R = -0.61, P = 0.012) but not in controls. Pulmonary blood volume was not altered by exercise and was similar between groups. Submaximal exercise elicited a greater accumulation of lung fluid in subjects with HFpEF compared with in controls, and lung fluid content was negatively correlated with lung diffusing capacity and alveolar-capillary membrane conductance in subjects with HFpEF.

Ultrasound of the Lungs: More than a Room with a View.

Lung ultrasound B-lines are the sonographic pattern of partial deaeration of the lung. In patients with pulmonary edema they are detected as multiple, diffuse, and bilateral, by placing the ultrasound probe in the intercostal spaces. B-lines can be used for bedside monitoring of pulmonary decongestion, and can guide diuretic therapy. Persistent pulmonary congestion after hospitalization for acute heart failure increases the risk of being rehospitalized in the following months. Adding B-lines assessment to echocardiography in an integrated cardiopulmonary ultrasound is of great value in establishing the kind and degree of myocardial and valvular impairment, and their hemodynamic consequences as pulmonary edema.

Effects of Carperitide on Degree of Pulmonary Congestion in Treatment of Acute Heart Failure.

BACKGROUND: Carperitide is used to treat acute heart failure (AHF) in Japan. Whether the degree of pulmonary congestion is associated with the effects of carperitide on AHF is unclear.Methods and Results:We retrospectively investigated the in-hospital outcomes and prognoses of 742 patients hospitalized for AHF between February 2015 and January 2017 and classified them into carperitide and non-carperitide groups, stratified according to the degree of pulmonary congestion. The median follow-up duration after admission was 231 days. In patients with moderate-severe pulmonary congestion, the rate of remaining congestion on chest X-ray at discharge was lower in the carperitide group than in the non-carperitide group (1.5% vs. 9.0%, P=0.004). Also, the carperitide group had significant reduction in a composite of all-cause death or rehospitalization for HF (adjusted hazard ratio, 0.62; 95% CI: 0.41-0.93; P=0.02). In patients with no-mild pulmonary congestion, carperitide was not associated with better clinical outcome. CONCLUSIONS: In the treatment of AHF with moderate-severe pulmonary congestion, carperitide is associated with more effective decongestion in the short term and better prognosis in the long term.

Mesenchymal stem cells therapeutic potential alleviate lipopolysaccharide-induced acute lung injury in rat model.

Inhalation of bacterial endotoxin induces an acute inflammation in the lower respiratory tract. The current study examined the therapeutic effects of bone marrow mesenchymal stem cells (BM-MSCs) in lipopolysaccharide (LPS)-induced pulmonary congestion in rats as compared with dexamethasone (Dexa) and sodium bicarbonate (NaHCO3 ). LPS (20 µL of LPS of Escherichia coli in each nostril for two consecutive days) induced lung injury as marked by an elevation of number of inflammatory cells especially neutrophils, increased total protein levels, elevation of lipid peroxidation, and reduction of reduced glutathione in bronchoalveolar lavage along with the reduction of reduced glutathione. These deleterious effects were hampered after treatment with BM-MSCs (1 × 106 cells/rat) once before acute lung injury (ALI) induction with LPS to an even better extent than Dexa (2 mg/kg once, ip) and NaHCO3 (10-15 mL/day for two consecutive days). In summary, BM-MSCs have the ability to suppress the endotoxin-induced systemic inflammatory response and could prove to be a novel approach to therapy for ALI in rats.

Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients.

AIMS: Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome). METHODS: We used LUS to examine 195 NYHA class II-IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline. RESULTS: In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated ≥3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (≥3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001). CONCLUSIONS: Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.

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.

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.

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.

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.

Prognostic significance of pulmonary arterial wedge pressure estimated by deep learning in acute heart failure.

AIMS: Acute decompensated heart failure (ADHF) presents with pulmonary congestion, which is caused by an increased pulmonary arterial wedge pressure (PAWP). PAWP is strongly associated with prognosis, but its quantitative evaluation is often difficult. Our prior work demonstrated that a deep learning approach based on chest radiographs can calculate estimated PAWP (ePAWP) in patients with cardiovascular disease. Therefore, the present study aimed to assess the prognostic value of ePAWP and compare it with other indices of haemodynamic congestion. METHODS AND RESULTS: We conducted a post hoc analysis of a single-centre, prospective, observational heart failure registry and analysed data from 534 patients admitted for ADHF between January 2018 and December 2019. The deep learning approach was used to calculate ePAWP from chest radiographs at admission and discharge. Patients were divided into three groups based on the ePAWP tertiles at discharge, as follows: first tertile group (ePAWP ≤ 11.2 mm Hg, n = 178), second tertile group (11.2 < ePAWP < 13.5 mm Hg, n = 170), and third tertile group (ePAWP ≥ 13.5 mm Hg, n = 186). The third tertile group had a higher prevalence of atrial fibrillation and lower systolic blood pressure at admission; a lower platelet count and higher total bilirubin at both admission and discharge; and a higher left atrial diameter, peak early diastolic transmitral flow velocity, right ventricular end-diastolic diameter, and maximal inferior vena cava diameter at discharge. During the median follow-up period of 289 days, 223 (41.7%) patients reached the primary endpoint (a composite of all-cause mortality or rehospitalization for heart failure). Kaplan-Meier analysis revealed a significantly higher composite event rate in the third tertile group (log-rank test, P = 0.006). Even when adjusted for clinically relevant factors, a higher ePAWP at discharge and a smaller decrease in ePAWP from admission to discharge were significantly associated with higher event rates [ePAWP at discharge: hazard ratio, 1.10; 95% confidence interval (CI), 1.02-1.19; P = 0.010; and size of ePAWP decrease: hazard ratio, 0.94; 95% CI, 0.89-0.99; P = 0.038]. CONCLUSIONS: Our study suggests that ePAWP calculated by a deep learning approach may be useful for identifying and monitoring pulmonary congestion during hospitalization for ADHF.