Diagnostic accuracy of lung ultrasound for identification of elevated left ventricular filling pressure

doi:10.1016/j.ijcard.2019.01.055

International Journal of Cardiology

Volume 281, 15 April 2019, Pages 62-68

https://doi.org/10.1016/j.ijcard.2019.01.055 Get rights and content

Highlights

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ASE/EACVI recommendation for the estimation of left ventricular filling pressure is quite complex and time consuming.
•
B-lines, in lung ultrasound, could constitute an interesting tool for LVFP evaluation in clinical practice, but data regarding their association with invasive hemodynamics are lacking.
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Clinical variables had a C-index of 79% to identify elevated LVEDP.
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Total B-lines number was higher in the elevated LVEDP group (1.0vs17.0, p < 0.0001) and significantly increased diagnostic accuracy (C-index increase = 15.5%, p = 0.004) and a net reclassification index (NRI = 142.0, 108.5–175.6, p < 0.0001) on top of clinical variables.
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In contrast, the 2016 ASE/EACVI recommendations did not significantly increase neither the reclassification nor the diagnostic accuracy. There is an important diagnostic capacity of B-lines to identify elevated filling pressure and that is probably something to consider in our clinical routine.

Abstract

Aims

The current algorithm in transthoracic echocardiography (TTE) proposed in the 2016 ASE/EACVI recommendation for the estimation of left ventricular filling pressure (LVFP) is quite complex and time-consuming. B-lines, in lung ultrasonography (LUS), could constitute an interesting tool for LVFP evaluation in clinical practice, although data regarding their association with invasive haemodynamics are lacking. The purpose of this study was to explore the diagnostic accuracy of B-lines in identifying elevated left ventricular end-diastolic pressure (LVEDP).

Method and results

81 adults with significant dyspnoea (NYHA ≥ 2) were prospectively analyzed by LUS in four areas in each hemithorax and a complete TTE within four hours prior to coronary angiography. Twenty-eight patients had elevated LVEDP. Clinical variables yielded a C-index of 79% to identify elevated LVEDP. The number of total B-lines was higher in the elevated LVEDP group (1.0vs17.0, p < 0.0001) and significantly increased the diagnostic accuracy (C-index increase = 10.5%, p = 0.002) and net reclassification index (NRI = 145.4, 113.0–177.9, p < 0.0001) on top of clinical variables.

Conclusion

This study demonstrates the substantial diagnostic capacity of B-lines to identify elevated LVEDP, which appears superior to that of classical echocardiographic strategies. This tool should be considered in a multi-parametric approach in patients with heart failure.

Introduction

Echocardiography is currently the gold standard in the routine evaluation of left ventricular filling pattern in patients with dyspnoea and/or heart failure. The 2016 American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines for the evaluation of left ventricular diastolic function [1] reported a new algorithm to assess the presence and severity (grade 1 to 3) of diastolic dysfunction (DD) and to estimate Left Ventricular Filling Pressure (LVFP). This algorithm, based on the estimation of left atrial volume, E wave, velocity, e’ septal and lateral velocity by Tissue Doppler Imaging (TDI), and maximal tricuspid velocity is quite complex and time-consuming.

B-lines (also called “comet-tail artefacts” or “lung comet”) are linear artefacts that are observed during lung ultrasonography (LUS), reflecting extravascular lung water [2]. LUS is simple and can be applied quickly at a patient's bedside with the same probe that is used for echocardiography. The utility of B-line quantification for the diagnosis of acute pulmonary oedema has been demonstrated in multiple studies. B-line number shows a good correlation with chest radiography findings, brain natriuretic peptide levels and E/e’ ratio [[3], [4], [5], [6]]. In patients with subclinical pulmonary congestion, the assessment of B-lines allows the diagnosis of subclinical pulmonary congestion and is strongly associated with clinical outcome [[7], [8], [9]]. With regard to the ASE/EACVI joint recommendations which can be difficult to apply in the presence of severe valvulopathy and/or atrial fibrillation, B-line quantification can be performed in these clinical conditions and is associated with clinical outcome regardless of underlying heart disease [10]. Moreover, echocardiographic algorithms are influenced by ageing given its strong association with diastolic function impairment; this may decrease the diagnostic accuracy for elevated LVFP in these patients [11]. B-lines could therefore constitute a valuable bedside tool for LVFP evaluation in routine clinical practice. A previous study [12] reported a good association of B-line count and right catheter haemodynamics although did not evaluate diagnostic accuracy per se and included mostly young patients (a third of the patients were included after heart transplant). Data regarding the association between B-lines and left cardiac haemodynamics in non-transplanted elderly patients are still lacking.

The purpose of this study was to explore the diagnostic accuracy of B-lines to identify elevated left ventricular end-diastolic pressure (LVEDP), as assessed by left heart catheterization (LHC).

Section snippets

Study sample

We prospectively included 93 adults (≥18 years old) with significant dyspnoea (NYHA≥2) who underwent a coronary angiography with left heart catheterization from May 2016 to July 2017. Patients with mitral stenosis (because of significant differences in LVEDP compared to other heart disease), known pulmonary fibrosis, pneumonia, active lung cancer or a history of recent chest trauma were excluded. Patients who had any change in diuretic treatment between Transthoracic Echocardiography (TTE) and

Patient characteristics

Among the 81 analyzed patients (Fig. 1, panel A), 28 had elevated LVEDP (Table 1). Patients with elevated LVEDP were more likely to have diabetes, chronic obstructive pulmonary disease (COPD) and heart failure. There were no significant differences in the proportion of history of chronic kidney disease, severe heart valve diseases, atrial fibrillation (AF) and coronary disease.

Differences in lung and heart ultrasonography variables according to LVEDP

A marked difference was identified in B-line count according to LVEDP level (median B-line count 1.0 (0.0–4.0) in

Discussion

In this study, B-line count as measured by lung ultrasonography (LUS) was the variable most strongly correlated with invasively measured LVEDP, and significantly increased both diagnostic accuracy and reclassification for elevated LVEDP. Strikingly, none of the left-sided recorded echocardiographic parameters correlated well with LVEDP or were associated with a similarly important increase in diagnostic accuracy for elevated LVEDP. In contrast, peak TR velocity and vena cava diameter were

Conclusion

This study demonstrates the important diagnostic capacity of B-lines in identifying elevated left ventricular end-diastolic pressure. This tool should be considered in a multi-parametric approach of patients with HF. The simplicity of LUS and IVC diameter measurement allows the use of a hand-held device to quickly, easily and adequately evaluate LV filling pressure.

Conflicts of interests

None.

Acknowledgements

We thank Jean-Loup Machu for the statistical editing of the manuscript.

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Citation Excerpt :
In a next revision of recommendations, decreasing the value placed on e′ and E/e′, which frequently lead to misclassifications, could be discussed. Other simple tools, pulmonary vein Doppler (Hubert et al. 2019) or perhaps more feasible systematic assessment of B-lines in eight locations could increase our ability to optimally estimate LV filling pressure (Omar et al. 2017). Dynamic tests (diastolic stress test) and a more usual use of the Valsalva maneuver could probably be considered as well.
The 2016 American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) guidelines for the evaluation of left ventricular diastolic function reported a new algorithm to assess diastolic function and to estimate left ventricular filling pressure (LVFP). At least five to six different parameters were necessary to conclude, each of them with their own inter-observer variability. This article examines the reproducibility of each parameter of the algorithm and its influence on the final decision of the clinician. Echocardiographic exams of 12 non-selected patients without any known cardiac disease or follow-up but addressed to the hospital for symptoms were analyzed by two readers (one junior and one senior) in five French cardiologic tertiary centers. Inter-observer reproducibility at each step of the algorithm and final decision were analyzed. There was mild agreement on the final decision. The main reasons of discrepancy were disagreement on the significance of mitral annular calcifications and measured values that are just around the cut-off (despite good reproducibility, a slight variation could lead to misclassification of a dichotomous choice between a normal measure and a pathologic measure). Without considering performance, this multicentric French study puts forward limits to the actual algorithm recommended for LVFP pattern assessment. Agreement is excellent in caricatural (easy) cases (left ventricular pressure clearly normal or clearly elevated) but a great discordance exists in the gray zone. Improvement in the algorithm and in the method for LVFP determination is proposed.

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View full text

Diagnostic accuracy of lung ultrasound for identification of elevated left ventricular filling pressure

Highlights

Abstract

Aims

Method and results

Conclusion

Introduction

Section snippets

Study sample

Patient characteristics

Differences in lung and heart ultrasonography variables according to LVEDP

Discussion

Conclusion

Conflicts of interests

Acknowledgements

J. Am. Soc. Echocardiogr.

J. Am. Soc. Echocardiogr. Off. Publ. Am. Soc. Echocardiogr.

Am. J. Cardiol.

J. Card. Fail.

JACC Cardiovasc. Imaging

Int. J. Cardiol.

Int. J. Cardiol.

Am. J. Med.

Chest

Mayo Clin. Proc.

J. Am. Soc. Echocardiogr.

Am. Heart J.

Int. J. Cardiol.

Am. J. Med.

Int. J. Cardiol.

Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides☆

Eur. J. Heart Fail.