Early changes in diaphragmatic function evaluated using ultrasound in cardiac surgery patients: a cohort study.

Little is known about the evolution of diaphragmatic function in the early post-cardiac surgery period. The main purpose of this work is to describe its evolution using ultrasound measurements of muscular excursion and thickening fraction (TF). Single-center prospective study of 79 consecutive uncomplicated elective cardiac surgery patients, using motion-mode during quiet unassisted breathing. Excursion and TF were measured sequentially for each patient [pre-operative (D1), 1 day (D2) and 5 days (D3) after surgery]. Pre-operative median for right and left hemidiaphragmatic excursions were 1.8 (IQR 1.6 to 2.1) cm and 1.7 (1.4 to 2.0) cm, respectively. Pre-operative median right and left thickening fractions were 28 (19 to 36) % and 33 (22 to 51) %, respectively. At D2, there was a reduction in both excursion (right: 1.5 (1.1 to 1.8) cm, p < 0.001, left: 1.5 (1.1 to 1.8), p = 0.003) and thickening fractions (right: 20 (15 to 34) %, p = 0.021, left: 24 (17 to 39) %, p = 0.002), followed by a return to pre-operative values at D3. A positive moderate correlation was found between excursion and thickening fraction (Spearman's rho 0.518 for right and 0.548 for left hemidiaphragm, p < 0.001). Interobserver reliability yielded a bias below 0.1 cm with limits of agreement (LOA) of ± 0.3 cm for excursion and - 2% with LOA of ± 21% for thickening fractions. After cardiac surgery, the evolution of diaphragmatic function is characterized by a transient impairment followed by a quick recovery. Although ultrasound diaphragmatic excursion and thickening fraction are correlated, excursion seems to be a more feasible and reproducible method in this population

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study

Cardiac imaging; Myocardial injury; Noncardiac surgeryImatge cardíaca; Lesió del miocardi; Cirurgia no cardíacaImagen cardiaca; Lesión miocárdica; Cirugía no cardiacaBackground Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. Methods Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48–72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. Results We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). Conclusion This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes.The study has been supported by research grant from the Instituto de Salud Carlos III, Spain (PI16/01162), partly funded by Fondo Europeo de Desarrollo Regional (FEDER), Unión Europea, “Una manera de hacer Europa” to Ekaterine Popova, by Generalitat de Catalunya (PERIS SLT017/20/000089) to Ekaterine Popova and by a "Marato de TV3" grant (20150110) to Pablo Alonso-Coello

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

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

Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort.

Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation–SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE US score, should be further studied before expanding its use in AHF patients.post-print2977 K

Clinical picture, management and risk stratification in patients with cardiogenic shock: does gender matter?

Background: Early recognition and risk stratification are crucial in cardiogenic shock (CS). A lower adherence to recommendations has been described in women with cardiovascular diseases. Little information exists about disparities in clinical picture, management and performance of risk stratification tools according to gender in patients with CS. Methods: Data from the multicenter Red-Shock registry were used. All consecutive patients with CS were included. Both CardShock and IABP-SHOCK II risk scores were calculated. The primary end-point was in-hospital mortality. The discriminative ability of both scores according to gender was assessed by binary logistic regression, calculating Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC). Results: A total of 793 patients were included, of whom 222 (28%) were female. Women were significantly older and had a lower proportion of chronic obstructive pulmonary disease and prior myocardial infarction. CS was less often related to acute coronary syndromes (ACS) in women. The use of vasoactive drugs, renal replacement therapy, invasive ventilation, therapeutic hypothermia and mechanical circulatory support was similar between both groups. In-hospital mortality was 346/793 (43.6%). Mortality was not significantly different according to gender (p = 0.194). Cardshock risk score showed a good ability for predicting in-hospital mortality both in man (AUC 0.69) and women (AUC 0.735). Likewise, the IABP-II successfully predicted in-hospital mortality in both groups (man: AUC 0.693; women: AUC 0.722). Conclusions: No significant differences were observed regarding management and in-hospital mortality according to gender. Both the CardShock and IABP-II risk scores depicted a good ability for predicting mortality also in women with CS

Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'. A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2). In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows

Adrenomedullin : a marker of impaired hemodynamics, organ dysfunction, and poor prognosis in cardiogenic shock

Background: The clinical CardShock risk score, including baseline lactate levels, was recently shown to facilitate risk stratification in patients with cardiogenic shock (CS). As based on baseline parameters, however, it may not reflect the change in mortality risk in response to initial therapies. Adrenomedullin is a prognostic biomarker in several cardiovascular diseases and was recently shown to associate with hemodynamic instability in patients with septic shock. The aim of our study was to evaluate the prognostic value and association with hemodynamic parameters of bioactive adrenomedullin (bio-ADM) in patients with CS. Methods: CardShock was a prospective, observational, European multinational cohort study of CS. In this sub-analysis, serial plasma bio-ADM and arterial blood lactate measurements were collected from 178 patients during the first 10 days after detection of CS. Results: Both bio-ADM and lactate were higher in 90-day non-survivors compared to survivors at all time points (P <0.05 for all). Lactate showed good prognostic value during the initial 24 h (AUC 0.78 at admission and 0.76 at 24 h). Subsequently, lactate returned normal ( 55.7 pg/mL) at 48 h compared to those with low bio-ADM levels (49.1 vs. 22.6%, P = 0.001). High levels of bio-ADM were associated with impaired cardiac index, mean arterial pressure, central venous pressure, and systolic pulmonary artery pressure during the study period. Furthermore, high levels of bio-ADM at 48 to 96 h were related to persistently impaired cardiac and end-organ function. Conclusions: Bio-ADM is a valuable prognosticator and marker of impaired hemodynamics in CS patients. High levels of bio-ADM may show shock refractoriness and developing end-organ dysfunction and thus help to guide therapeutic approach in patients with CS.Peer reviewe

Aplicación de la ecografía pulmonar a la valoración clínica de los pacientes con insuficiencia cardíaca

Introducción La insuficiencia cardiaca (IC) es un problema de salud de primer orden marcado por una elevada tasa de ingresos hospitalarios. La congestión es una de las principales causas de tales hospitalizaciones, y su detección constituye un reto clínico. Las líneas B en el estudio ecográfico pulmonar han mostrado una buena correlación con el agua extravascular pulmonar y constituyen un potente predictor de mortalidad y reingreso. Sin embargo, se desconoce si su monitorización pudiera resultar útil para guiar el tratamiento y modificar el pronóstico de la IC. Hipótesis El seguimiento de los pacientes con insuficiencia cardiaca guiado por ecografía pulmonar es seguro y reducirá la tasa de descompensaciones después de un ingreso hospitalario. El número de líneas B se correlacionará con otros parámetros de congestión y será un marcador pronóstico por sí solo. Métodos Estudio LUS-HF I. Ensayo clínico aleatorizado, unicéntrico y simple ciego. Los pacientes se incluyeron el día del alta tras un ingreso por IC y se aleatorizaron a un grupo de seguimiento convencional o a un grupo experimental de seguimiento con ecografía pulmonar. Se realizaron visitas de seguimiento a los 15 días, 1,3 y 6 meses. En todos los pacientes se realizó ecografía pulmonar, pero solo en el caso del grupo experimental se le comunicaba el resultado al médico tratante. El objetivo principal fue un evento combinado de visita urgente u hospitalización por empeoramiento de la IC o muerte por cualquier causa a 6 meses. Estudio LUS-HF II. Estudio de correlación entre las presiones endocavitarias medidas mediante cateterismo derecho y el número de líneas B, en situación basal y tras un test vasodilatador o de reactividad. Resultados Estudio LUS-HF I. Desde el 10 de noviembre de 2016 hasta el 19 de junio de 2018 se incluyeron 123 pacientes, 61 en el grupo experimental y 62 en el grupo control. El evento combinado ocurrió en el 40% de los pacientes del grupo control y en el 23% del grupo experimental, lo que supuso una hazard ratio de 0.518 (intervalo de confianza del 95%, 0.268-0.998, p=0.049) y un número de pacientes necesario a tratar de 5 para evitar un evento. La reducción de eventos se debió principalmente a una reducción de las visitas urgentes. El seguimiento con ecografía pulmonar fue seguro sin aumentar el ingreso por hipotensión, diselectrolitemias o insuficiencia renal respecto al grupo control. Además, el número de líneas B se correlacionó de forma significativa con la mayoría de los marcadores de congestión y mejoró la predicción pronóstica de puntuaciones de riesgo validadas en IC. Estudio LUS-HF II. El número de líneas B presentó una buena correlación con las presiones endocavitarias, especialmente con la presión pulmonar diastólica y el capilar. No se observó un descenso relevante del número de líneas B tras el test vasodilatador pero sí un aumento significativo tras un test de reactividad, con una elevada correlación con el aumento de la presión capilar pulmonar. Conclusiones Una estrategia de tratamiento guiado por ecografía pulmonar mejoró el pronóstico a 6 meses de los pacientes ingresados por IC. El número de líneas B se correlacionó con otros parámetros de congestión, especialmente con las presiones endocavitarias, y su adición a las escalas de riesgo validadas en IC mejoró su predicción pronóstica. Su carácter no invasivo, fácil aprendizaje y bajo coste apoyan su incorporación al seguimiento de los pacientes con IC.Aims Pulmonary congestion is the most important cause of hospitalizations in patients with heart failure (HF) and is therefore a primary goal of therapy. However, clinical assessment of pulmonary congestion is often limited by the low sensitivity and specificity of physical examination. Lung ultrasound (LUS) is a useful tool to assess subclinical pulmonary congestion and to stratify the prognosis of patients with HF. The aim of our study was to evaluate whether a LUS-guided follow-up protocol improves the outcomes of patients with HF. Hypothesis A LUS-guided treatment is superior to the standard of care in ambulatory patients after hospitalisation for HF during a 6-month follow-up. The number of B-lines will be correlated with other markers of congestion and will be a potent prognostic marker. Methods LUS-HF I study. This is a single-blind, randomized clinical trial. Patients admitted for HF were allocated at discharge to either a) standard follow-up, or b) LUS-guided follow-up. The primary end-point was a composite of urgent visit, hospitalisation for worsening HF, or death during a 6 month follow-up. Visits were scheduled at 15, 30, 90, and 180 days after discharge. Treating physicians were encouraged to modify diuretic therapy in accordance with the number of B-lines recorded by LUS in the LUS-guided group. LUS-HF II Study. The aim was to assess the correlation between the number of B-lines and intracardiac pressures measured during a right heart catheterization. ResultsLUS-HF I Study. From November 2016 to June 2018, we randomized 123 patients admitted for HF, 62 to the standard follow-up and 61 to the LUS-guided follow-up. The LUS-guided strategy had a hazard ratio of 0.518 (95% CI, 0.268-0.998, p=0.049) for the primary outcome, mainly due to a decrease in the number of urgent visits for worsening HF. The number of patients needed to treat to avoid an event was 5. Safety parameters were similar in the two groups. Moreover, the number of B-lines had a good correlation with other markers of congestion and improved the prognostic performance of validated risk scores in HF. LUS-HF II Study. The number of B-lines had a good correlation with intracardiac pressures, especially with the diastolic and wedge (PCWP) pulmonary pressures. Despite a reduction in the PCWP pressure with a vasodilatory challenge the number of B-lines was relatively constant. On the other hand, an increase of the number of B-lines was observed simultaneously to an increase in the PCWP. Conclusions Tailored LUS-guided diuretic treatment of pulmonary congestion reduced the number of decompensations in patients with HF. The number of B-lines had a good correlation with other markers of congestion and improved the prognostic performance of validated risk scores in HF. LUS is a non-invasive, safe, and easy-to-use technique with potential clinical applicability to guide pulmonary congestion treatment in patients with HF

Aplicación de la ecografía pulmonar a la valoración clínica de los pacientes con insuficiencia cardíaca

Introducción La insuficiencia cardiaca (IC) es un problema de salud de primer orden marcado por una elevada tasa de ingresos hospitalarios. La congestión es una de las principales causas de tales hospitalizaciones, y su detección constituye un reto clínico. Las líneas B en el estudio ecográfico pulmonar han mostrado una buena correlación con el agua extravascular pulmonar y constituyen un potente predictor de mortalidad y reingreso. Sin embargo, se desconoce si su monitorización pudiera resultar útil para guiar el tratamiento y modificar el pronóstico de la IC. Hipótesis El seguimiento de los pacientes con insuficiencia cardiaca guiado por ecografía pulmonar es seguro y reducirá la tasa de descompensaciones después de un ingreso hospitalario. El número de líneas B se correlacionará con otros parámetros de congestión y será un marcador pronóstico por sí solo. Métodos Estudio LUS-HF I. Ensayo clínico aleatorizado, unicéntrico y simple ciego. Los pacientes se incluyeron el día del alta tras un ingreso por IC y se aleatorizaron a un grupo de seguimiento convencional o a un grupo experimental de seguimiento con ecografía pulmonar. Se realizaron visitas de seguimiento a los 15 días, 1,3 y 6 meses. En todos los pacientes se realizó ecografía pulmonar, pero solo en el caso del grupo experimental se le comunicaba el resultado al médico tratante. El objetivo principal fue un evento combinado de visita urgente u hospitalización por empeoramiento de la IC o muerte por cualquier causa a 6 meses. Estudio LUS-HF II. Estudio de correlación entre las presiones endocavitarias medidas mediante cateterismo derecho y el número de líneas B, en situación basal y tras un test vasodilatador o de reactividad. Resultados Estudio LUS-HF I. Desde el 10 de noviembre de 2016 hasta el 19 de junio de 2018 se incluyeron 123 pacientes, 61 en el grupo experimental y 62 en el grupo control. El evento combinado ocurrió en el 40% de los pacientes del grupo control y en el 23% del grupo experimental, lo que supuso una hazard ratio de 0.518 (intervalo de confianza del 95%, 0.268-0.998, p=0.049) y un número de pacientes necesario a tratar de 5 para evitar un evento. La reducción de eventos se debió principalmente a una reducción de las visitas urgentes. El seguimiento con ecografía pulmonar fue seguro sin aumentar el ingreso por hipotensión, diselectrolitemias o insuficiencia renal respecto al grupo control. Además, el número de líneas B se correlacionó de forma significativa con la mayoría de los marcadores de congestión y mejoró la predicción pronóstica de puntuaciones de riesgo validadas en IC. Estudio LUS-HF II. El número de líneas B presentó una buena correlación con las presiones endocavitarias, especialmente con la presión pulmonar diastólica y el capilar. No se observó un descenso relevante del número de líneas B tras el test vasodilatador pero sí un aumento significativo tras un test de reactividad, con una elevada correlación con el aumento de la presión capilar pulmonar. Conclusiones Una estrategia de tratamiento guiado por ecografía pulmonar mejoró el pronóstico a 6 meses de los pacientes ingresados por IC. El número de líneas B se correlacionó con otros parámetros de congestión, especialmente con las presiones endocavitarias, y su adición a las escalas de riesgo validadas en IC mejoró su predicción pronóstica. Su carácter no invasivo, fácil aprendizaje y bajo coste apoyan su incorporación al seguimiento de los pacientes con IC.Aims Pulmonary congestion is the most important cause of hospitalizations in patients with heart failure (HF) and is therefore a primary goal of therapy. However, clinical assessment of pulmonary congestion is often limited by the low sensitivity and specificity of physical examination. Lung ultrasound (LUS) is a useful tool to assess subclinical pulmonary congestion and to stratify the prognosis of patients with HF. The aim of our study was to evaluate whether a LUS-guided follow-up protocol improves the outcomes of patients with HF. Hypothesis A LUS-guided treatment is superior to the standard of care in ambulatory patients after hospitalisation for HF during a 6-month follow-up. The number of B-lines will be correlated with other markers of congestion and will be a potent prognostic marker. Methods LUS-HF I study. This is a single-blind, randomized clinical trial. Patients admitted for HF were allocated at discharge to either a) standard follow-up, or b) LUS-guided follow-up. The primary end-point was a composite of urgent visit, hospitalisation for worsening HF, or death during a 6 month follow-up. Visits were scheduled at 15, 30, 90, and 180 days after discharge. Treating physicians were encouraged to modify diuretic therapy in accordance with the number of B-lines recorded by LUS in the LUS-guided group. LUS-HF II Study. The aim was to assess the correlation between the number of B-lines and intracardiac pressures measured during a right heart catheterization. ResultsLUS-HF I Study. From November 2016 to June 2018, we randomized 123 patients admitted for HF, 62 to the standard follow-up and 61 to the LUS-guided follow-up. The LUS-guided strategy had a hazard ratio of 0.518 (95% CI, 0.268-0.998, p=0.049) for the primary outcome, mainly due to a decrease in the number of urgent visits for worsening HF. The number of patients needed to treat to avoid an event was 5. Safety parameters were similar in the two groups. Moreover, the number of B-lines had a good correlation with other markers of congestion and improved the prognostic performance of validated risk scores in HF. LUS-HF II Study. The number of B-lines had a good correlation with intracardiac pressures, especially with the diastolic and wedge (PCWP) pulmonary pressures. Despite a reduction in the PCWP pressure with a vasodilatory challenge the number of B-lines was relatively constant. On the other hand, an increase of the number of B-lines was observed simultaneously to an increase in the PCWP. Conclusions Tailored LUS-guided diuretic treatment of pulmonary congestion reduced the number of decompensations in patients with HF. The number of B-lines had a good correlation with other markers of congestion and improved the prognostic performance of validated risk scores in HF. LUS is a non-invasive, safe, and easy-to-use technique with potential clinical applicability to guide pulmonary congestion treatment in patients with HF