Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients

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Persisting congestion symptoms at discharge and during outpatient follow-ups are critical predictors of adverse outcomes. Lung ultrasound (LUS) has emerged as a simple, non-invasive tool for assessing pulmonary congestion. Objectives This study aims to evaluate the prognostic significance of pulmonary congestion detected via LUS in predicting short-term adverse events in patients hospitalized for acute heart failure (AHF). Methods We conducted a bi-centric prospective observational study involving consecutive patients admitted for AHF at two hospitals in Tunisia. Each participant underwent a thorough clinical assessment, biological evaluation, chest X-ray, LUS, and echocardiography. LUS operators were blinded to clinical data and examined eight thoracic zones. The primary outcomes included a composite of urgent care visits, rehospitalization due to acute heart failure decompensation, or cardiac death within a six-month follow-up. Results A total of 116 patients (median age: 69 years; 53% male; mean ejection fraction: 40%) were included. At discharge, the mean number of B-lines observed was 6.6 ± 3.3. During the follow-up period, we recorded 72 adverse events, with 52 patients experiencing severe heart failure symptoms requiring hospitalization and 20 dying from cardiac causes. Multivariate analysis indicated that the presence of ≥3 B-lines bilaterally significantly predicted the combined endpoint of rehospitalization or cardiac death at the six-month mark (HR: 11.024; 95% CI: 5.542-21.926; P < 0.001). Additionally, the number of B-lines decreased from 31.9 ± 12.7 upon admission to 6.6 ± 3.1 at discharge (P < 0.001). Conclusions The application of an 8-zone LUS protocol is effective in assessing the severity and monitoring the resolution of pulmonary congestion in heart failure patients. Persistent pulmonary congestion at discharge, as evaluated by LUS, correlates with a poorer prognosis. 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F1000Research 2025, 14 :1050 ( https://doi.org/10.12688/f1000research.167897.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] Mariem Jabeur https://orcid.org/0009-0005-4522-1426 1 , Selim Hammami https://orcid.org/0009-0006-7833-1602 1 , Selma Charfeddine 1 , [...] Amine Bahloul 1 , Hela Bouzidi https://orcid.org/0009-0001-9427-6096 2 , Ihsen Zairi 2 , Sofiene Kammoun 2 , Rania Gargouri https://orcid.org/0000-0002-0550-5898 1 , Sondes Kraiem 2 , Leila Abid 1 Mariem Jabeur https://orcid.org/0009-0005-4522-1426 1 , Selim Hammami https://orcid.org/0009-0006-7833-1602 1 , [...] Selma Charfeddine 1 , Amine Bahloul 1 , Hela Bouzidi https://orcid.org/0009-0001-9427-6096 2 , Ihsen Zairi 2 , Sofiene Kammoun 2 , Rania Gargouri https://orcid.org/0000-0002-0550-5898 1 , Sondes Kraiem 2 , Leila Abid 1 PUBLISHED 07 Oct 2025 Author details Author details 1 Cardiology, Hedi Chaker University Hospital, Sfax, Sfax, Tunisia 2 Cardiology, Habib Thameur Hospital, Tunis, Tunis, Tunisia Mariem Jabeur Roles: Conceptualization, Formal Analysis, Methodology, Supervision Selim Hammami Roles: Data Curation, Formal Analysis, Funding Acquisition, Writing – Original Draft Preparation Selma Charfeddine Roles: Investigation Amine Bahloul Roles: Investigation Hela Bouzidi Roles: Data Curation, Investigation, Supervision Ihsen Zairi Roles: Investigation Sofiene Kammoun Roles: Investigation Rania Gargouri Roles: Investigation Sondes Kraiem Roles: Supervision, Validation Leila Abid Roles: Supervision, Validation OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Pulmonary congestion, as opposed to low cardiac output, is the predominant cause of hospitalizations for heart failure and is associated with elevated mortality rates. Persisting congestion symptoms at discharge and during outpatient follow-ups are critical predictors of adverse outcomes. Lung ultrasound (LUS) has emerged as a simple, non-invasive tool for assessing pulmonary congestion. Objectives This study aims to evaluate the prognostic significance of pulmonary congestion detected via LUS in predicting short-term adverse events in patients hospitalized for acute heart failure (AHF). Methods We conducted a bi-centric prospective observational study involving consecutive patients admitted for AHF at two hospitals in Tunisia. Each participant underwent a thorough clinical assessment, biological evaluation, chest X-ray, LUS, and echocardiography. LUS operators were blinded to clinical data and examined eight thoracic zones. The primary outcomes included a composite of urgent care visits, rehospitalization due to acute heart failure decompensation, or cardiac death within a six-month follow-up. Results A total of 116 patients (median age: 69 years; 53% male; mean ejection fraction: 40%) were included. At discharge, the mean number of B-lines observed was 6.6 ± 3.3. During the follow-up period, we recorded 72 adverse events, with 52 patients experiencing severe heart failure symptoms requiring hospitalization and 20 dying from cardiac causes. Multivariate analysis indicated that the presence of ≥3 B-lines bilaterally significantly predicted the combined endpoint of rehospitalization or cardiac death at the six-month mark (HR: 11.024; 95% CI: 5.542-21.926; P < 0.001). Additionally, the number of B-lines decreased from 31.9 ± 12.7 upon admission to 6.6 ± 3.1 at discharge (P < 0.001). Conclusions The application of an 8-zone LUS protocol is effective in assessing the severity and monitoring the resolution of pulmonary congestion in heart failure patients. Persistent pulmonary congestion at discharge, as evaluated by LUS, correlates with a poorer prognosis. READ ALL READ LESS Keywords Acute heart failure, lung ultrasound, prognosis Corresponding Author(s) Mariem Jabeur ( [email protected] ) Close Corresponding author: Mariem Jabeur Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Jabeur M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Jabeur M, Hammami S, Charfeddine S et al. Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.12688/f1000research.167897.1 ) First published: 07 Oct 2025, 14 :1050 ( https://doi.org/10.12688/f1000research.167897.1 ) Latest published: 07 Oct 2025, 14 :1050 ( https://doi.org/10.12688/f1000research.167897.1 ) Introduction Heart failure (HF) is a prevalent and serious condition, characterized by the heart’s inability to pump effectively, leading to significant morbidity and mortality. Hospitalizations due to acute heart failure (AHF) have risen dramatically, with pulmonary congestion emerging as a predominant factor contributing to these admissions. Unlike low cardiac output, clinical congestion, manifested by symptoms such as dyspnea and edema, serves as the most frequent cause of hospitalization for heart failure and is a strong predictor of adverse outcomes, including increased mortality. 1 , 2 Despite advancements in the management of heart failure, patients often experience residual congestion at the time of discharge, which is not adequately addressed by conventional diagnostic methods. Traditional assessments such as clinical evaluations and chest X-rays have limitations in sensitivity and specificity for detecting elevated cardiac filling pressures. 3 Moreover, other biomarkers, like natriuretic peptides, can be influenced by various factors unrelated to cardiac dysfunction—such as renal function and body mass index—while patients are often on stable diuretic regimens. 4 Lung ultrasound (LUS) has emerged as a promising, non-invasive, and semi-quantitative tool for evaluating pulmonary congestion. This technique involves detecting vertical echogenic lines known as B-lines, which represent extravascular lung water and signify pulmonary congestion. Recent studies have suggested that the quantity of B-lines correlates with patient outcomes, identifying those at higher risk for adverse events after discharge. 5 , 6 The objective of this study is to assess the prognostic significance of pulmonary congestion as assessed by LUS in patients hospitalized for AHF. Specifically, we aim to evaluate how the presence of B-lines at the time of discharge correlates with short-term outcomes, including rehospitalization and cardiac mortality. Furthermore, we will describe the dynamic changes in LUS findings throughout the patient’s hospital stay. Through this investigation, we aim to establish LUS as an integral aspect of routine clinical evaluation in heart failure management, ultimately improving patient stratification and outcomes. Patients and methods Study design: This bi-centric prospective observational study was conducted at the Cardiology Departments of Hedi Chaker Hospital in Sfax and Habib Thameur Hospital in Tunis from July 1, 2022, to September 30, 2023. The study aimed to evaluate the prevalence and prognostic importance of pulmonary congestion assessed by lung ultrasound (LUS) in patients hospitalized for acute heart failure (AHF). Study population: We enrolled consecutive adult patients (≥18 years) admitted for AHF, regardless of the etiology and systolic function. All patients were required to meet the European Society of Cardiology criteria for heart failure diagnosis. Patients were excluded based on the following criteria: age 40, history of pneumothorax, lobectomy, or lung cancer, severe interstitial lung disease preventing adequate ultrasonography interpretation, and refusal to consent. Assessment methods: Upon hospital admission, each patient underwent a comprehensive evaluation, which included: 1. Clinical Examination: A detailed clinical assessment was performed to document symptoms, signs, and medical history. 2. Biological Evaluation: Blood tests were conducted to assess renal function, electrolytes, hemoglobin, and natriuretic peptides (NT-proBNP). 3. Chest X-ray: Standard chest imaging was performed to identify pulmonary congestion and other cardiopulmonary conditions. 4. Lung Ultrasound (LUS): LUS was performed within 2 hours of admission using an ultrasound device: • General Electric 6S-D sector array probe with a frequency range of 3 to 8 MHz at Hedi Chaker Hospital. • Sonosite M-Turbo 2D Echo sector array probe with a frequency of 7.5 MHz at Habib Thameur Hospital. Acute interstitial pulmonary syndrome was defined, according to the International Consensus Conference on LUS, by the presence of two or more positive regions in each hemithorax. 7 A positive region was defined by the presence of three or more B-lines in transverse intercostal plane. 8 , 9 The examination involved assessment of eight distinct thoracic zones to identify B-lines—vertical, echogenic lines extending from the pleura, indicative of pulmonary congestion. Operators performing LUS were blinded to the patients’ clinical data to prevent bias. 5. Echocardiography: Transthoracic echocardiography was conducted, as recommended by the American Society of Echocardiography. 10 , 11 To evaluate cardiac structure and function, including ejection fraction and other relevant parameters. Data analysis: Following discharge, patients were closely monitored for 180 days to document the occurrence of adverse outcomes, defined as a composite of urgent care visits, rehospitalization due to acute decompensation of heart failure, or cardiac death. Continuous variables were analyzed using appropriate statistical tests (e.g., Student’s t-test for normally distributed data and Mann-Whitney U test for non-normally distributed data). Categorical variables were evaluated using the Chi-squared test or Fisher’s exact test where applicable. Prognostic factors were assessed using univariate and multivariate Cox regression analyses to derive hazard ratios (HR) and confidence intervals (CI). Event-free survival was calculated using Kaplan-Meier curves, with differences between groups assessed using the log-rank test. A significance level of p < 0.05 was established. Ethics approval The study was approved by the Habib Thameur Hospital Ethics committee, Habib Thameur Teaching Hospital, Tunis, Tunisia, under approval/reference number HTHEC-2023-11. Results Study population: A total of 116 patients were included in the analysis, with a median age of 69 years (interquartile range: 62-75), and 62 patients (53%) were male. The mean left ventricular ejection fraction (LVEF) was 40% ± 10%. Patient demographics and clinical characteristics at baseline are summarized in Table I . Table I. Patient mean characteristics. All ( n = 116) B-Lines ≥3 N = 61 (52.6%) B-Lines <3 N = 55 (47.4%) P value Age (years) 68.99+/- 12.06 71.49 +/-10 66.15 +/-13.5 0.019 Male 62(53.4%) 31(50.8%) 31(56.4%) 0.580 Age CRF 101(87,1%) 57(93,4%) 44(80%) 0.029 Diabetes mellitus 48 (41.4%) 25(41%) 23(41.8%) 1 Dyslipidemia 47 (40.5%) 28(45.9%) 19(34.5%) 0.257 Hypertension 68(58.6%) 33(54.1%) 35(63.6%) 0.347 Smoking 27(23.3%) 14(23%) 13(23.6%) 1 CAD 28(24.1%) 14(23%) 14(25.5%) 0.829 HF 55(47.4%) 36(59%) 19(34.5%) 0.010 Arrhythmia 53(45.7%) 31(50.8%) 21(38.2%) 0.184 VHD 41(35.3%) 29(47.5%) 12(21.8%) 0.006 CRF 31(26.7%) 23(37.7%) 8(14.5%) 0.006 Baseline characteristics: Of the enrolled patients, key clinical characteristics included a history of hypertension in 67 patients (57.8%), diabetes in 45 patients (38.8%), and chronic kidney disease in 32 patients (27.6%). The mean plasma NT-proBNP level at admission was 1500 pg/mL (range: 500-4500 pg/mL). Table II presents a detailed overview of these clinical characteristics. Table II. Comparison of clinical parameters between the two groups. All ( n = 116) B-Lines ≥3 N = 61 (52.6%) B-Lines <3 N = 55 (47.4%) P value SBP (mmHg) 131.17+/-28.9 130.05+/-27.38 132.3+/-30.7 0.668 DBP (mmHg) 75.03+/-14.7 74.2 +/- 14.8 75.9+/-14.6 0.532 HR (per min) 91.98+/-25.65 90.5+/- 23 93.6+/-28 0.520 SpO2 (%) 92.68+/-5.1 92.4+/-5.2 92.8+/-5.18 0.690 RR (per min) 23.56 +/- 5.61 24.19+/-5.8 22.8+/-5.3 0.690 Lung ultrasound findings: At the time of discharge, the mean number of B-lines detected was 6.6 ± 3.3. Notably, during the hospital stay, the number of B-lines significantly decreased from a mean of 31.9 ± 12.7 upon admission to 6.6 ± 3.1 at discharge (p < 0.001). This decline demonstrates effective pulmonary decongestion among patients during their hospitalization. The distribution of B-lines was assessed bilaterally across the eight zones, with ≥3 B-lines recorded in 45 patients (38.8%) at discharge. Adverse clinical outcomes: During a mean follow-up period of six months, a total of 72 adverse events were documented. These included: • 52 patients (44.8%) were readmitted due to severe heart failure symptoms. • 20 patients (17.2%) experienced cardiac-related mortality. In-hospital mortality was recorded at 4.3%. The follow-up events for heart failure hospitalization or death were significantly associated with the number of B-lines detected at discharge. Statistical analysis of outcomes: Multivariate Cox regression analysis identified that the presence of ≥3 B-lines bilaterally at discharge was a strong predictor of adverse clinical outcomes, with a hazard ratio (HR) of 11.024 (95% CI: 5.542-21.926, p < 0.001) ( Table III ). • Patients with ≥3 B-lines had a significantly higher composite endpoint rate of rehospitalization or cardiac death compared to those with <3 B-lines (p < 0.001). • Event-free survival analysis showed that patients categorized with <3 B-lines exhibited a 76.4% event-free survival rate at six months (adjusted p < 0.001), whereas those with ≥3 B-lines had notably poorer outcomes. Table III. Predictors for combined endpoint of heart failure hospitalization or decompensation or cardiac death at 180-day follow-up by multivariable Cox regression analysis. Combined Endpoint HR 95% CI P value Positive Zone Bilaterally >=1 at discharge 11.024 5.542-21.926 0.000 Diuretics 0.424 0.227-0.791 0.007 Heart Failure 1.589 0.981-2.573 0.060 Natremia = 45 mmHg 2.049 0.596-7.042 0.255 Age CRF 0.565 0.204-1.561 0.271 Blines at discharge 1.034 0.806-1.328 0.790 Kaplan-Meier survival curves : Figure 1 illustrates the Kaplan-Meier event-free survival curves. The differences in survival between patients with ≥3 B-lines versus <3 B-lines were statistically significant (log-rank test, p < 0.001), further reinforcing the prognostic importance of LUS findings in this cohort. Figure 1. Event-free survival curves for both death and HF hospitalization regarding the number of B-lines. Summary of key findings • Patient Cohort: 116 patients, median age 69 years. • B-lines: Mean of 6.6 ± 3.3 at discharge; significant decrease from 31.9 ± 12.7 at admission (p < 0.001). • Adverse Events: 72 events; 52 readmissions (44.8%) and 20 cardiac deaths (17.2%). • Predictive Value of B-lines: ≥3 B-lines at discharge associated with higher risk of adverse outcomes (HR 11.024, p < 0.001). • Event-Free Survival: 76.4% in <3 B-lines group at six months. Discussion Previous studies have demonstrated the value of LUS as a diagnostic tool for acute heart failure (AHF). LUS showed a sensitivity of 94.2% and specificity of 77.5% for diagnosing AHF. 12 This study aimed to assess the prognostic significance of pulmonary congestion evaluated by lung ultrasound (LUS) in patients hospitalized for acute heart failure (HF). Our findings provide compelling evidence that residual pulmonary congestion, quantified through the number of B-lines at discharge, serves as a crucial predictor of adverse short-term outcomes, including rehospitalization and cardiac mortality. Prognostic significance of B-Lines: The multivariate analysis revealed that having ≥3 B-lines bilaterally at discharge is an independent predictor for the combined endpoint of heart failure hospitalization or cardiac death at the 180-day follow-up, with a hazard ratio of 11.024 (95% CI 5.542-21.926, P < 0.001). This finding corroborates earlier studies which have illustrated that persistent pulmonary congestion correlates with significantly higher risks of rehospitalization and mortality, underscoring the importance of monitoring B-lines as an integral part of patient assessment. 1 , 2 , 13 – 15 The identification of this threshold within our study supports the clinical utility of LUS as a non-invasive and effective method for risk stratification. Dynamic monitoring of lung congestion: Furthermore, the significant decrease in the number of B-lines from admission (31.9 ± 12.7) to discharge (6.6 ± 3.3, P < 0.001) illustrates the effective therapeutic interventions aimed at alleviating congestion. This dynamic monitoring capability of LUS not only enhances clinicians’ understanding of fluid status but also allows for timely adjustments in treatment strategies. 16 , 17 The potential to visualize and quantify the resolution of pulmonary congestion can significantly refine patient management, promoting better clinical outcomes in the follow-up phase. Of note, data on the concomitant decline of B-line counts and natriuretic peptides are conflicting. 18 – 20 Natriuretic peptide clearance in an acute setting appears to exhibit slower kinetics when compared with B-line variations to therapy, especially in the presence of renal failure. Divergent results have also been reported for E/e’, 18 , 19 although definitive conclusions cannot be drawn given the small size of these studies. Event-free survival correlation: Our study further indicates that patients with <3 B-lines at discharge exhibit a markedly improved event-free survival rate of 76.4% over six months. This finding suggests that LUS may be instrumental in identifying low-risk patients, enabling medical teams to tailor follow-up and preventive strategies more effectively. The integration of LUS into routine assessment alongside traditional clinical indicators can enhance the overall management of heart failure. Multidimensional approach to management: Complementing LUS with traditional assessments and biomarkers, such as natriuretic peptides, represents a significant advancement in the multidimensional management of heart failure. Although NT-proBNP is valuable, its levels can be influenced by various factors unrelated to cardiac function. 1 In contrast, LUS provides a direct evaluation of pulmonary congestion, thereby offering a more reliable prognostic tool. 4 Longitudinal studies and theoretical framework: Longitudinal studies have shown that the presence of pulmonary congestion, as indicated by B-lines, remains a stronger predictor of adverse outcomes than other biomarkers measured at discharge. Volpicelli et al. 20 documented a correlation between B-line clearance and symptomatic relief, demonstrating that rapid resolution of pulmonary edema could significantly improve clinical outcomes. This relationship underscores the importance of LUS not only in initial assessments but also in monitoring treatment efficacy over time. Limitations and areas for future research: However, this study does have limitations. The lack of routine NT-proBNP assessments at discharge restricts our ability to correlate these findings with changes in neurohormonal status, an important facet of heart failure management. Moreover, while our study focuses on a diverse patient population representative of real-world clinical settings, this diversity could contribute to variability in the prognostic implications of the B-line count. Future studies should aim to validate the prognostic value of LUS in larger, homogenous cohorts, and explore long-term outcomes associated with persistent pulmonary congestion. Additionally, the relative short follow-up duration may limit our understanding of the full impact of persistent pulmonary congestion on long-term outcomes. Extending follow-up periods in future studies could yield insights into the chronic implications of post-discharge congestion assessments. In summary, our research emphasizes the critical role of LUS in the management of acute heart failure, showcasing its potential to improve patient outcomes through effective monitoring and intervention. By integrating LUS into routine clinical practice, healthcare providers can better identify high-risk patients, facilitate timely treatment adjustments, and ultimately enhance the overall care provided to individuals suffering from heart failure. Conclusion In conclusion, this study demonstrates that lung ultrasound (LUS) is a valuable, non-invasive tool for assessing pulmonary congestion in patients with acute heart failure (HF). The quantification of B-lines, particularly at discharge, has shown to be a significant predictor of adverse outcomes, such as rehospitalization and cardiac mortality, within a six-month follow-up period. Specifically, the identification of three or more B-lines serves as a critical indicator of patients at heightened risk for exacerbations, reinforcing the necessity for enhanced monitoring and targeted interventions. Patient consent Informed consent was obtained in writing from all participants prior to their inclusion in the study Data availability statement All datasets generated and analyzed during the current study are available in the Zenodo repository Zenodo. Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients . 21 This project contains the following underlying data: • Data.docx Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). The dataset can be accessed at: https://doi.org/10.5281/zenodo.17113545 . 21 References 1. Coiro S, Rossignol P, Ambrosio G, et al. : Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur. J. Heart Fail. 2015; 17 (11): 1172–1181. PubMed Abstract | Publisher Full Text 2. Gargani L, Pang PS, Frassi F, et al. : Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: A lung ultrasound study. Cardiovasc. Ultrasound. 2015; 13 (1): 40. PubMed Abstract | Publisher Full Text | Free Full Text 3. Wang CS, FitzGerald JM, Schulzer M, et al. : Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005; 294 (15): 1944–1956. PubMed Abstract 4. Logeart D, Thabut G, Jourdain P, et al. : Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure. J. Am. Coll. Cardiol. 2004; 43 (4): 635–641. PubMed Abstract | Publisher Full Text 5. Lichtenstein D, Mézière G, Biderman P, et al. : The comet-tail artifact: An ultrasound sign of alveolar-interstitial syndrome. Am. J. Respir. Crit. Care Med. 1997; 156 (5): 1640–1646. Publisher Full Text 6. Picano E, Gargani L: Ultrasound lung comets: The shape of lung water. Eur. J. Heart Fail. 2012; 14 : 1194–1196. PubMed Abstract | Publisher Full Text 7. Volpicelli G, Elbarbary M, Blaivas M, et al. : International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012; 38 : 577–591. PubMed Abstract | Publisher Full Text 8. Picano E, Frassi F, Agricola E, et al. : Ultrasound lung comets: A clinically useful sign of extravascular lung water. J. Am. Soc. Echocardiogr. 2006; 19 : 356–363. PubMed Abstract 9. Soldati G, Copetti R, Sher S: Sonographic interstitial syndrome the sound of lung water. J. Ultrasound Med. 2009; 28 (2): 163–174. Publisher Full Text 10. Lang RM, Badano LP, Mor-Avi V, et al. : Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American society of echocardiography and the European association of cardiovascular imaging. Eur. Heart J. Cardiovasc. Imaging. 2015; 16 (3): 233–271. PubMed Abstract | Publisher Full Text 11. Lancellotti P, Galderisi M, Edvardsen T, et al. : Echo-Doppler estimation of left ventricular filling pressure: Results of themulticentre EACVI Euro-Filling study. Eur. Heart J. Cardiovasc. Imaging. 2017; 18 (9): 961–968. PubMed Abstract | Publisher Full Text 12. Bouzidi H, et al. : ROLE OF PULMONARY ULTRASONOGRAPHY IN DIAGNOSIS OFACUTE HEART FAILURE. Curr. Probl. Cardiol. Oct. 01, 2024; 50 : p. 102910. Elsevier BV. PubMed Abstract | Publisher Full Text 13. Palazzuoli A, Ruocco G, Beltrami M, et al. : Combined use of lung ultrasound, B-type natriuretic peptide, and echocardiography for outcome prediction in patients with acute HFrEF and HFpEF. Clin. Res. Cardiol. 2018; 107 (7): 586–596. PubMed Abstract | Publisher Full Text 14. Platz E, Campbell RT, Claggett B, et al. : Lung Ultrasound in Acute Heart Failure: Prevalence of Pulmonary Congestion and Short- and Long-Term Outcomes. JACC Hear Fail. 2019; 7 (10). 15. Volpicelli G, Mussa A, Garofalo G, et al. : Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am. J. Emerg. Med. 2006; 24 (6): 689–696. PubMed Abstract | Publisher Full Text 16. Gargani L, Frassi F, Soldati G, et al. : Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: A comparison with natriuretic peptides. Eur. J. Heart Fail. 2008; 10 (1): 70–77. PubMed Abstract | Publisher Full Text 17. Frassi F, Gargani L, Gligorova S, et al. : Clinical and echocardiographic determinants of ultrasound lung comets. Eur. J. Echocardiogr. 2007; 8 (6): 474–479. PubMed Abstract | Publisher Full Text 18. Facchini C, Malfatto G, Giglio A, et al. : Lung ultrasound and transthoracic impedance for noninvasive evaluation of pulmonary congestion in heart failure. J. Cardiovasc. Med. 2016; 17 (7): 510–517. PubMed Abstract | Publisher Full Text 19. Öhman J, Harjola VP, Karjalainen P, et al. : Assessment of early treatment response by rapid cardiothoracic ultrasound in acute heart failure: Cardiac filling pressures, pulmonary congestion and mortality. Eur Hear journal Acute Cardiovasc care. 2018; 7 (4): 311–320. Publisher Full Text 20. Volpicelli G, Caramello V, Cardinale L, et al. : Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am. J. Emerg. Med. 2008; 26 (5): 585–591. Publisher Full Text 21. Jabeur M: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients. Zenodo. 5 septembre 2025. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Oct 2025 ADD YOUR COMMENT Comment Author details Author details 1 Cardiology, Hedi Chaker University Hospital, Sfax, Sfax, Tunisia 2 Cardiology, Habib Thameur Hospital, Tunis, Tunis, Tunisia Mariem Jabeur Roles: Conceptualization, Formal Analysis, Methodology, Supervision Selim Hammami Roles: Data Curation, Formal Analysis, Funding Acquisition, Writing – Original Draft Preparation Selma Charfeddine Roles: Investigation Amine Bahloul Roles: Investigation Hela Bouzidi Roles: Data Curation, Investigation, Supervision Ihsen Zairi Roles: Investigation Sofiene Kammoun Roles: Investigation Rania Gargouri Roles: Investigation Sondes Kraiem Roles: Supervision, Validation Leila Abid Roles: Supervision, Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 07 Oct 2025, 14:1050 https://doi.org/10.12688/f1000research.167897.1 Copyright © 2025 Jabeur M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Jabeur M, Hammami S, Charfeddine S et al. Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.12688/f1000research.167897.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 07 Oct 2025 Views 0 Cite How to cite this report: Lubis AC. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425319 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425319 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Jan 2026 Anggia Chairuddin Lubis , Universitas Sumatera Utara, Medan, Indonesia Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.185042.r425319 Dear all authors, thank you for presenting an interesting 180-day cohort from two centers evaluating the prognostic role of lung ultrasound (LUS) in patients with acute heart failure, irrespective of the systolic function. The authors found that LUS is an ... Continue reading READ ALL Dear all authors, thank you for presenting an interesting 180-day cohort from two centers evaluating the prognostic role of lung ultrasound (LUS) in patients with acute heart failure, irrespective of the systolic function. The authors found that LUS is an effective and simple tool for assessing pulmonary congestion severity, monitoring congestion resolution, and predicting a poorer prognosis. Moreover, several comments and questions were raised from this manuscript. Firstly, the terminology was not precise. The definitions of arrhythmia, valvular heart disease, chronic renal failure, and operator criteria were not mentioned. On the other hand, echocardiography was clearly mentioned; however, no result reflected the echocardiographic findings. Secondly, it would be helpful if the authors could provide the medication information patients received, as it is closely related to decongestion response and patients' prognosis. Thirdly, a significant reduction in B-lines was observed as a measure of decongestion effectiveness; however, substantial residual congestion remained. This underlines the need for better clarification of ≥ 3 B-lines threshold used in this cohort. Finally, this cohort limitation was a limited sample size and a short follow-up duration. The conclusion should also address that this finding was limited to a brief observation period. Best regards. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Lubis AC. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425319 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425319 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Nugent K. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425318 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425318 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 Nov 2025 Kenneth Nugent , Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA Approved VIEWS 0 https://doi.org/10.5256/f1000research.185042.r425318 Jabeur and co- authors have evaluated a cohort of patients hospitalized with acute heart failure to determine the value of lungs ultrasound in predicting prognosis. This study included 116 patients with a mean age of 69 and a mean ejection ... Continue reading READ ALL Jabeur and co- authors have evaluated a cohort of patients hospitalized with acute heart failure to determine the value of lungs ultrasound in predicting prognosis. This study included 116 patients with a mean age of 69 and a mean ejection fraction of 40%. The mean number of B-lines of 6.6±3.3 at discharge. During the follow-up. There were 72 adverse events with patients having increasing heart failure symptoms or dying from cardiac causes. Their analysis indicated that having 3 or more B-lines bilaterally predicted the combined end point of hospitalization or cardiac death at the 6-month mark. Consequently, this study would suggest that measuring the number of B-lines in patients during their hospitalization and at discharge can help with evaluation and help predict prognosis. In my view, these results are quite clear, and the manuscript is well-written. It might be useful if the authors included an example of an ultrasound with 3 or more B-lines so that the reader can understand what you are talking about better. Also, the authors might suggest the maximum number of B-lines present at discharge which is associated with better prognosis. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Pulmonary medicine and critical care I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Nugent K. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425318 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425318 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Salamanca J. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425313 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425313 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 27 Oct 2025 Jorge Salamanca , Cardiology Department, Hospital Universitario de La Princesa. Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.185042.r425313 This prospective bi-centric observational study from Tunisia assessed the prognostic value of pulmonary congestion evaluated by lung ultrasound (LUS) in 116 patients hospitalized for acute heart failure (AHF). Using an eight-zone protocol, congestion was defined as ≥ 3 B-lines bilaterally ... Continue reading READ ALL This prospective bi-centric observational study from Tunisia assessed the prognostic value of pulmonary congestion evaluated by lung ultrasound (LUS) in 116 patients hospitalized for acute heart failure (AHF). Using an eight-zone protocol, congestion was defined as ≥ 3 B-lines bilaterally at discharge. Over a six-month follow-up, 72 adverse events occurred (52 readmissions and 20 cardiac deaths). Persistent congestion independently predicted the composite endpoint of HF rehospitalization or cardiac death (HR 11.0, 95 % CI 5.5–21.9, p < 0.001). The mean B-line count declined from 31.9 ± 12.7 at admission to 6.6 ± 3.3 at discharge (p < 0.001). The authors conclude that residual congestion detected by LUS at discharge identifies patients at higher short-term risk and supports its role as a simple, non-invasive prognostic tool. Major comments: -The topic is clinically relevant, but the study’s novelty is limited since the prognostic role of discharge LUS findings has already been demonstrated in multiple cohorts (PMID: 26417699, 31667987, 36769421). The authors should clarify what differentiates their dataset—such as regional characteristics, protocol standardization, or follow-up approach. -Please, include a patient-flow diagram summarizing inclusion and exclusion. -Clarify whether all patients had both admission and discharge LUS, and whether inter-observer reproducibility was assessed between centers. -Provide more detailed echocardiographic variables (E/e’, left atrial volume, pulmonary pressures, IVC diameter) to relate pulmonary and systemic congestion. -The chosen threshold of “≥ 3 B-lines bilaterally” requires justification. Current consensus statements (PMID: 31218825; 37450604) standardize the technique—using 6–8 scanning zones, clips ≥ 6 seconds per zone, and defining a positive zone as ≥ 3 B-lines. For pre-discharge risk stratification, these same documents indicate that ≥ 2 positive zones in an 8-zone protocol identify patients at higher short-term risk of adverse outcomes. -Please clarify how your protocol aligns with or diverges from these standardized recommendations, and justify why a binary criterion of “≥ 3 B-lines bilaterally” was selected instead of the zone-based approach endorsed by current international guidelines. -Consider ROC analysis to determine the optimal B-line threshold instead of fixed dichotomization. -Define clearly the components and adjudication of the composite endpoint. -Kaplan–Meier curves should include risk tables and p-values. -The discussion should move beyond confirming known associations to address mechanisms and practical implications (e.g., follow-up intensity, guided therapy). -Expand the discussion to explicitly contrast methodology, thresholds, and follow-up results with the main prior studies [Reference 1, Reference 2, Reference 3] to contextualize the findings. Minor comments: -Confirm whether both centers obtained separate ethics approvals. -Describe management of missing data. -Indicate operator training and inter-observer agreement (ICC or κ). -Ensure consistent terminology (“B-lines”, “HF”, “LUS”). Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly References 1. Coiro S, Rossignol P, Ambrosio G, Carluccio E, et al.: Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. European Journal of Heart Failure . 2015; 17 (11): 1172-1181 Publisher Full Text 2. Rivas‐Lasarte M, Álvarez‐García J, Fernández‐Martínez J, Maestro A, et al.: Lung ultrasound‐guided treatment in ambulatory patients with heart failure: a randomized controlled clinical trial (LUS‐HF study). European Journal of Heart Failure . 2019; 21 (12): 1605-1613 Publisher Full Text 3. Pugliese N, Mazzola M, Bandini G, Barbieri G, et al.: Prognostic Role of Sonographic Decongestion in Patients with Acute Heart Failure with Reduced and Preserved Ejection Fraction: A Multicentre Study. Journal of Clinical Medicine . 2023; 12 (3). Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Heart failure I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Salamanca J. Reviewer Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425313 ) The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425313 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Oct 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 1 07 Oct 25 read read read Jorge Salamanca , Hospital Universitario de La Princesa. Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain Kenneth Nugent , Texas Tech University Health Sciences Center, Lubbock, USA Anggia Chairuddin Lubis , Universitas Sumatera Utara, Medan, Indonesia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Lubis A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Jan 2026 | for Version 1 Anggia Chairuddin Lubis , Universitas Sumatera Utara, Medan, Indonesia 0 Views copyright © 2026 Lubis A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear all authors, thank you for presenting an interesting 180-day cohort from two centers evaluating the prognostic role of lung ultrasound (LUS) in patients with acute heart failure, irrespective of the systolic function. The authors found that LUS is an effective and simple tool for assessing pulmonary congestion severity, monitoring congestion resolution, and predicting a poorer prognosis. Moreover, several comments and questions were raised from this manuscript. Firstly, the terminology was not precise. The definitions of arrhythmia, valvular heart disease, chronic renal failure, and operator criteria were not mentioned. On the other hand, echocardiography was clearly mentioned; however, no result reflected the echocardiographic findings. Secondly, it would be helpful if the authors could provide the medication information patients received, as it is closely related to decongestion response and patients' prognosis. Thirdly, a significant reduction in B-lines was observed as a measure of decongestion effectiveness; however, substantial residual congestion remained. This underlines the need for better clarification of ≥ 3 B-lines threshold used in this cohort. Finally, this cohort limitation was a limited sample size and a short follow-up duration. The conclusion should also address that this finding was limited to a brief observation period. Best regards. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Lubis AC. Peer Review Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425319) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425319 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Nugent K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Nov 2025 | for Version 1 Kenneth Nugent , Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA 0 Views copyright © 2025 Nugent K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Jabeur and co- authors have evaluated a cohort of patients hospitalized with acute heart failure to determine the value of lungs ultrasound in predicting prognosis. This study included 116 patients with a mean age of 69 and a mean ejection fraction of 40%. The mean number of B-lines of 6.6±3.3 at discharge. During the follow-up. There were 72 adverse events with patients having increasing heart failure symptoms or dying from cardiac causes. Their analysis indicated that having 3 or more B-lines bilaterally predicted the combined end point of hospitalization or cardiac death at the 6-month mark. Consequently, this study would suggest that measuring the number of B-lines in patients during their hospitalization and at discharge can help with evaluation and help predict prognosis. In my view, these results are quite clear, and the manuscript is well-written. It might be useful if the authors included an example of an ultrasound with 3 or more B-lines so that the reader can understand what you are talking about better. Also, the authors might suggest the maximum number of B-lines present at discharge which is associated with better prognosis. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Pulmonary medicine and critical care I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Nugent K. Peer Review Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425318) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425318 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Salamanca J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 27 Oct 2025 | for Version 1 Jorge Salamanca , Cardiology Department, Hospital Universitario de La Princesa. Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain 0 Views copyright © 2025 Salamanca J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This prospective bi-centric observational study from Tunisia assessed the prognostic value of pulmonary congestion evaluated by lung ultrasound (LUS) in 116 patients hospitalized for acute heart failure (AHF). Using an eight-zone protocol, congestion was defined as ≥ 3 B-lines bilaterally at discharge. Over a six-month follow-up, 72 adverse events occurred (52 readmissions and 20 cardiac deaths). Persistent congestion independently predicted the composite endpoint of HF rehospitalization or cardiac death (HR 11.0, 95 % CI 5.5–21.9, p < 0.001). The mean B-line count declined from 31.9 ± 12.7 at admission to 6.6 ± 3.3 at discharge (p < 0.001). The authors conclude that residual congestion detected by LUS at discharge identifies patients at higher short-term risk and supports its role as a simple, non-invasive prognostic tool. Major comments: -The topic is clinically relevant, but the study’s novelty is limited since the prognostic role of discharge LUS findings has already been demonstrated in multiple cohorts (PMID: 26417699, 31667987, 36769421). The authors should clarify what differentiates their dataset—such as regional characteristics, protocol standardization, or follow-up approach. -Please, include a patient-flow diagram summarizing inclusion and exclusion. -Clarify whether all patients had both admission and discharge LUS, and whether inter-observer reproducibility was assessed between centers. -Provide more detailed echocardiographic variables (E/e’, left atrial volume, pulmonary pressures, IVC diameter) to relate pulmonary and systemic congestion. -The chosen threshold of “≥ 3 B-lines bilaterally” requires justification. Current consensus statements (PMID: 31218825; 37450604) standardize the technique—using 6–8 scanning zones, clips ≥ 6 seconds per zone, and defining a positive zone as ≥ 3 B-lines. For pre-discharge risk stratification, these same documents indicate that ≥ 2 positive zones in an 8-zone protocol identify patients at higher short-term risk of adverse outcomes. -Please clarify how your protocol aligns with or diverges from these standardized recommendations, and justify why a binary criterion of “≥ 3 B-lines bilaterally” was selected instead of the zone-based approach endorsed by current international guidelines. -Consider ROC analysis to determine the optimal B-line threshold instead of fixed dichotomization. -Define clearly the components and adjudication of the composite endpoint. -Kaplan–Meier curves should include risk tables and p-values. -The discussion should move beyond confirming known associations to address mechanisms and practical implications (e.g., follow-up intensity, guided therapy). -Expand the discussion to explicitly contrast methodology, thresholds, and follow-up results with the main prior studies [Reference 1, Reference 2, Reference 3] to contextualize the findings. Minor comments: -Confirm whether both centers obtained separate ethics approvals. -Describe management of missing data. -Indicate operator training and inter-observer agreement (ICC or κ). -Ensure consistent terminology (“B-lines”, “HF”, “LUS”). Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly References 1. Coiro S, Rossignol P, Ambrosio G, Carluccio E, et al.: Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. European Journal of Heart Failure . 2015; 17 (11): 1172-1181 Publisher Full Text 2. Rivas‐Lasarte M, Álvarez‐García J, Fernández‐Martínez J, Maestro A, et al.: Lung ultrasound‐guided treatment in ambulatory patients with heart failure: a randomized controlled clinical trial (LUS‐HF study). European Journal of Heart Failure . 2019; 21 (12): 1605-1613 Publisher Full Text 3. Pugliese N, Mazzola M, Bandini G, Barbieri G, et al.: Prognostic Role of Sonographic Decongestion in Patients with Acute Heart Failure with Reduced and Preserved Ejection Fraction: A Multicentre Study. Journal of Clinical Medicine . 2023; 12 (3). Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Heart failure I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Salamanca J. Peer Review Report For: Assessing the Prognostic Value of Lung Ultrasound in Detecting Pulmonary Congestion in Acute Heart Failure Patients [version 1; peer review: 1 approved, 2 not approved] . F1000Research 2025, 14 :1050 ( https://doi.org/10.5256/f1000research.185042.r425313) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1050/v1#referee-response-425313 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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