Background: The use of urinary sodium to guide diuretics in acute heart failure is recommended by experts and the most recent European Society of Cardiology guidelines. However, there are limited data to support this recommendation. The ENACT-HF study (Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure) investigated the feasibility and efficacy of a standardized natriuresis-guided diuretic protocol in patients with acute heart failure and signs of volume overload. Methods: ENACT-HF was an international, multicenter, open-label, pragmatic, 2-phase study, comparing the current standard of care of each center with a standardized diuretic protocol, including urinary sodium to guide therapy. The primary end point was natriuresis after 1 day. Secondary end points included cumulative natriuresis and diuresis after 2 days of treatment, length of stay, and in-hospital mortality. All end points were adjusted for baseline differences between both treatment arms. Results: Four hundred one patients from 29 centers in 18 countries worldwide were included in the study. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P <0.001). After 2 days, the natriuresis remained higher in the protocol arm (538 versus 365 mmol; adjusted mean ratio, 1.52; P <0.001), with a significantly higher diuresis (5776 versus 4381 mL; adjusted mean ratio, 1.33; P <0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P =0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P =0.852). Conclusions: A standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.

Dear Madam and Sir, We kindly thank you for writing us concerning our published article entitled: “Vascularization of Primary, Peripheral Lung Carcinoma in CEUS” [1]. Of course the researcher and the examiner should bear in mind that the blood supply and the hemodynamics of the pulmonary circulation could depend on several possible, variable parameters. The Euler-Liljestrand reflex (hypoxic vasoconstriction), comorbidities (e. g. pulmonary hypertension and heart failure), cancer location [2], neoangiogenesis [3], vessel obstruction by tumor infiltration [4] and thrombosis by e. g. micrometastasis have to mentioned. This is even more important in quantitative measurements. The extent to which these parameters practically affect vascularization often remains unclear. Thus, the time to enhancement is not useful to discriminate between a BA and a PA pattern. The dual blood supply of the lung nevertheless offers two different vascularization patterns when examining with CEUS. On the one hand, we can depict enhancement before systemic vascularization emerges (chest wall enhancement), defined as PA here. On the other hand, enhancement is seen simultaneously or after systemic vascularization, called BA here. In the case of an occluded pulmonary artery (branch), we would expect BA vascularization, whereas a PA pattern might include tumor vascularization by pulmonary artery and the pulmonary capillaries as well as the “Sperrarterien” and bronchial arteries. We totally agree with the letter writer that hepatic and lung vasculatures differ on the microscopic level. Hayek described “Sperrarterien” of the lungs – thick wall vessel connections between the pulmonary artery and the bronchial artery, which are normally closed. In the case of hypoxic events like a pulmonary embolism, these “Sperrarterien” are opened and blood from the bronchial arteries flows into the distal parts of the pulmonary artery [5]. However, it is unclear whether and how these anastomoses contribute to lung cancer vascularization. Selective angiography studies showed no anastomoses [6] or broncho-pulmonary anastomoses in just a couple of patients [7]. A postmortem angiography study on lung resectates visualized several bronchopulmonary anastomoses and the pulmonary and bronchial vascularization pattern [2]. We examined patients with dorsal lung consolidations in a sitting position (n = 58, 65 %) and those with ventral lung consolidation in a half-sitting position (n = 31, 35 %). Whether a sitting or supine examination position influences CEUS vascularization in lung carcinoma has not yet been investigated to our knowledge. In terms of air bronchograms, we hypothesized that lepidic adenocarcinomas are associated with distributed/branched air bronchograms and that tumor necrosis, independently of the tumor histology, shows local “spotted” air bronchograms. It’s just a descriptive attempt to differentiate air bronchograms by ultrasound parameters. A pathological correlation is of course desirable. Of course, it would be nice and necessary to further investigate lung carcinoma vascularization by comparative studies using angiography, CT/MRI angiography, ultrasound (CEUS), V/P-scan, PET and pathologic samples.

Purpose: To assess the diagnostic performance of contrast-enhanced ultrasound (CEUS) alongside contrast-enhanced computed tomography (CECT) in evaluating central lung cancer (CLC). Materials and Methods: From 2006 to 2022, 54 patients with CLC and obstructive atelectasis (OAT) underwent standardized examinations using CEUS in addition to CECT. The ability to differentiate CLC from atelectatic tissue in CECT and CEUS was categorized as distinguishable or indistinguishable. In CEUS, in distinguishable cases, the order of enhancement (time to enhancement) (OE; categorized as either an early pulmonary arterial [PA] pattern or a delayed bronchial arterial [BA] pattern of enhancement), the extent of enhancement (EE; marked or reduced), the homogeneity of enhancement (HE; homogeneous or inhomogeneous), and the decrease in enhancement (DE; rapid washout [<120 s] or late washout [≥120 s]) were evaluated. Results: The additional use of CEUS improved the diagnostic capability of CECT from 75.9% to 92.6% in differentiating a CLC from atelectatic tissue. The majority of CLC cases exhibited a BA pattern of enhancement (89.6%), an isoechoic reduced enhancement (91.7%), and a homogeneous enhancement (91.7%). Rapid DE was observed in 79.2% of cases. Conclusions: In cases of suspected CLC with obstructive atelectasis, the application of CEUS can be helpful in differentiating tumor from atelectatic tissue and in evaluating CLC.

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Purpose To evaluate B-mode ultrasound (B-US) and contrast-enhanced ultrasound (CEUS) patterns of focal splenic incidentalomas (FSIs), and to correlate ultrasound patterns with benignity and malignancy via histologic examination and/or the clinical course. Materials and Methods Between 2004 and 2021, 139 consecutive patients with an FSI detected by B-US were investigated additionally with CEUS. On CEUS, the arterial enhancement (AE) of the FSI (hyperenhancement, isoenhancement, hypoenhancement, and absent enhancement) was analyzed. Subsequently, the malignancy rate according to different B-US echo patterns and CEUS perfusion patterns was determined. Results The final diagnosis of FSI was malignant in 9/139 (6.5%) and benign in 130/139 (93.5%) cases. The hypoechoic and hyperechoic lesions on B-US with arterial hyperenhancement on CEUS and the echogenic cystic or complex lesions on B-US with predominantly absent enhancement on CEUS were benign in 54/54 (100%) cases. 6/37 (16.2%) hypoechoic lesions on B-US with arterial hypo-/isoenhancement on CEUS and 3/48 (6.3%) of hyperechoic lesions on B-US with an arterial hypo-/isoenhancement on CEUS were malignant. Conclusion Based on these results, FSIs reveal different malignancy rates depending on the B-US und CEUS patterns, and classification according to these B-US and CEUS patterns may be helpful in further evaluation of an FSI.