Pulmonary congestion during Exercise stress Echocardiography in Hypertrophic Cardiomyopathy

Eszter Dalma Pálinkás, Federica Re, Jesus Peteiro, Milorad Tesic, Attila Pálinkás, Marco Antonio Rodrigues Torres, Ana Djordjevic Dikic, Branko Beleslin, Caroline M. Van De Heyning, Maria Grazia D’Alfonso, Fabio Mori, Quirino Ciampi, José Luis de Castro Silva Pretto, Iana Simova, Viktória Nagy, Krisztina Boda, Róbert Sepp, Iacopo Olivotto, Patricia A. Pellikka, Eugenio Picano

Research output: Contribution to journalArticlepeer-review


Background: B-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, have not been systematically evaluated in patients with hypertrophic cardiomyopathy (HCM). Aim: To assess the clinical, anatomical and functional correlates of pulmonary congestion elicited by exercise in HCM. Methods: We enrolled 128 HCM patients (age 52 ± 15 years, 72 males) consecutively referred for ESE (treadmill in 46, bicycle in 82 patients) in 10 quality-controlled centers from 7 countries (Belgium, Brazil, Bulgaria, Hungary, Italy, Serbia, Spain). ESE assessment at rest and peak stress included: mitral regurgitation (MR, score from 0 to 3); E/e’; systolic pulmonary arterial pressure (SPAP) and end-diastolic volume (EDV). Change from rest to stress was calculated for each variable. Reduced preload reserve was defined by a decrease in EDV during exercise. B-lines at rest and at peak exercise were assessed by lung ultrasound with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥ 2. Results: LUS was feasible in all subjects. B-lines were present in 13 patients at rest and in 38 during stress (10 vs 30%, p < 0.0001). When compared to patients without stress B-lines (n = 90), patients with B-lines (n = 38) had higher resting E/e’ (14 ± 6 vs. 11 ± 4, p = 0.016) and SPAP (33 ± 10 vs. 27 ± 7 mm Hg p = 0.002). At peak exercise, patients with B-lines had higher peak E/e’ (17 ± 6 vs. 13 ± 5 p = 0.003) and stress SPAP (55 ± 18 vs. 40 ± 12 mm Hg p < 0.0001), reduced preload reserve (68 vs. 30%, p = 0.001) and an increase in MR (42 vs. 17%, p = 0.013) compared to patients without congestion. Among baseline parameters, the number of B-lines and SPAP were the only independent predictors of exercise pulmonary congestion. Conclusions: Two-thirds of HCM patients who develop pulmonary congestion on exercise had no evidence of B-lines at rest. Diastolic impairment and mitral regurgitation were key determinants of pulmonary congestion during ESE. These findings underscore the importance of evaluating hemodynamic stability by physiological stress in HCM, particularly in the presence of unexplained symptoms and functional limitation.

Original languageEnglish (US)
JournalInternational Journal of Cardiovascular Imaging
StatePublished - Dec 1 2022


  • B-lines
  • Echocardiography
  • Exercise stress echocardiography
  • Hypertrophic cardiomyopathy
  • Pulmonary congestion

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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