Prognostic value of the ultrasonic determination of the degree of interstitial edema in patients with intermediate ejection fraction of the left ventricle after treating acute decompensation of heart failure

Aim To study ultrasonic characteristics of lung tissue in patients with heart failure with left ventricular (LV) mid-range ejection fraction (HFmEF) and predictive value of these characteristics after reversing acute decompensated heart failure (ADHF).
Material and methods Ultrasonic characteristics of lung tissue were studied by prospective observation in 71 patients (mean age, 65.2±3.6 years; men, 64.3 %) with HFmEF (LVEF from 40 to 49 %) following ADHF reversal. Semiquantitative evaluation of B-lines was performed by the E. Picano (2016) method at 5+2 days after hospitalization and on discharge from the hospital. The distance between B-lines was 3 mm (В3 lines) and 7 mm (В7 lines). Patients’ catamnesis was studied for determining the predictive value of lung tissue ultrasonic characteristics for two years since the index hospitalization. Statistical analysis was performed using the McNemar’s χ2 test (for evaluation of linked samples and of changes in the presence/absence of B-lines as determined by lung ultrasound examination (USE)) and the Wilcoxon test (for evaluation of quantitative changes). Differences were considered significant at p<0.05.
Results B7-lines characteristic of interstitial component of pulmonary parenchymal edema prevailed in patients with HFmEF. В3-lines characteristic of alveolar edema were found in a small amount. In the anterior-superior segment, B7-lines predominated over B3-lines (80 % vs. 20 %, p<0.01) on the right; however, on the lest, significant differences were not observed (64 % vs. 36 %, p>0.05). In the anterior-inferior segment, В7-lines prevailed over В3-lines on the right (75 % vs. 25 %, p<0.05); however, on the left, the difference was not significant (67 % vs. 33 %, p=0.05). In the lateral superior segment on the right, В7-lines predominated over В3-lines (75 % vs. 25 %, p<0.01); in contrast, on the left, there were no differences (67 % vs. 33 %, p>0.05). In lateral-basal segments on both sides, significant differences were present (73 % vs. 27 % on the right, p<0.05; 72 % vs. 28 % on the lest, p<0.05). The results of lung ultrasound were also used for evaluation of the B-line predictive value in patients with ADHF and mid-range EF on discharge from the hospital after reversal of X-ray and clinical symptoms of pulmonary congestion. In the next two years, 35 patients (49.2 % of sample) were rehospitalized with signs of ADHF (39 hospitalizations, 1.1 hospitalizations per patient). The rehospitalized patients were divided into two subgroups, with an increased number of B-lines and small congestion on discharge (6–15 В-lines) and without signs of congestion (<5 В-lines). For patients with a minimal (small) congestion on pulmonary ultrasound but regression of clinical and X-ray congestion, the number of rehospitalizations was 25 vs. 11 in patients with the number of B7-lines <5. In the ROC-analysis, the area under the curve was 0.706, which corresponded to the expert assessment as “good”. The position sensitivity was 78.6 % and the specificity was 79.7 %.
Conclusion “Ultrasonic pulmonary edema syndrome” in patients with LV mid-range ejection fraction after reversing ADHF was characterized by predomination of the interstitial component, despite the absence of X-ray congestion, correlated with the blood level of NT-proBNP measured at the same time, and was associated with rehospitalizations.

1. Chuchalin A.G. Pulmonary edema : clinical forms. Atmosphere. Pulmonology and Allergology. 2005;3:2–7.

2. Montoya F.C., Safarova A.F., Kobalava Zh.D., Soloveva A.E., Lobzhanizde T.V. Lung ultrasound in patients with decompensated heart failure with preserved and reduced left ventricular ejection fraction: a prospective study. International journal of heart and vascular diseases. 2019;7(22):4–15.

3. Petrov A.A., Safarova A.F., Rachina S.A., Kobalava Zh.D., Safarova N.B., Tesakov I.P. et al. Ultrasound examination of lungs: procedure and role in diagnosis of nosocomial pneumonia. Practical pulmonology. 2018;3:38–45.

4. Mareev V.Yu., Fomin I.V., Ageev F.T., Begrambekova Yu.L., Vasyuk Yu.A., Garganeeva A.A. et al. Russian Heart Failure Society, Russian Society of Cardiology. Russian Scientific Medical Society of Internal Medicine Guidelines for Heart failure: chronic (CHF) and acute decompensated (ADHF). Diagnosis, prevention and treatment. Kardiologiia. 2018;58(6S):8–158. DOI: 10.18087/cardio.2475

5. Picano E, Pellikka PA. Ultrasound of extravascular lung water: a new standard for pulmonary congestion. European Heart Journal. 2016;37(27):2097–104. DOI: 10.1093/eurheartj/ehw164

6. Picano E, Scali MC, Ciampi Q, Lichtenstein D. Lung Ultrasound for the Cardiologist. JACC: Cardiovascular Imaging. 2018;11(11):1692–705. DOI: 10.1016/j.jcmg.2018.06.023

7. Cabello F.E., Soloveva A.E., Safarova A.F., Kobalava Zh.D. Evaluation of pulmonary congestion in heart failure: methodologyfor survey, clinical prognostic valuesof lung ultrasound. Difficult patient. 2017;15(6–7):19–23.

8. Miglioranza MH, Picano E, Badano LP, Sant’Anna R, Rover M, Zaffaroni F et al. Pulmonary congestion evaluated by lung ultrasound predicts decompensation in heart failure outpatients. International Journal of Cardiology. 2017; 240:271–8. DOI: 10.1016/j.ijcard.2017.02.150

9. Platz E, Merz AA, Jhund PS, Vazir A, Campbell R, McMurray JJ. Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review: Lung ultrasound in acute and chronic heart failure. European Journal of Heart Failure. 2017;19(9):1154–63. DOI: 10.1002/ejhf.839

10. Skorodumova E.G., Kostenko V.A., Skorodumova E.A., Siverinа A.V. Assessment of interstitial edema in patients with intermediate function of the left ventricle after resolving of acute decompensation of heart failure. Translational Medicine. 2018;5(3):23–7. DOI: 10.18705/2311-4495-2018-5-3-23-27

11. Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E et al. Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202–10. DOI: 10.1378/chest.14-2608