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Purpose: B-lines (also called ultrasound lung comets) are a simple lung ultrasound sign of pulmonary congestion, that correlate with extra-vascular lung water content. Our aim was to assess the prognostic value of B-lines in patients with heart failure and left ventricular systolic dysfunction, and to compare it with clinical and echocardiographic parameters.Methods: We evaluated on admission 412 consecutive in-patients (age 68±12 years, 327 males) with heart failure and systolic dysfunction (ejection fraction [EF]<50%), with a comprehensive 2-D and Doppler echocardiography, and lung ultrasound with B-lines assessment. A patient B-line score was obtained by summing the number of B-lines from 28 scanning sites on anterior and lateral right and left hemithoraxes, from the second to the fifth intercostal spaces, as previously described.Results: All patients were followed-up for a median period of 18 (interquartile range 6-28) months. During the follow-up, 59 deaths and 38 hospitalizations for worsening dyspnoea occurred. Prognosis was progressively more severe with increasing B-lines number (see figure). At univariate analysis, B-lines were more powerful predictors (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.4-2.5) than other echocardiographic variables of recognized prognostic value, including EF (HR .95, CI .93-.97), and pulmonary artery systolic pressure (HR 1.03, CI 1.01-1.04). On multivariate analysis, B-lines provided additional prognostic information (HR 1.8, CI 1.3-2.3) on creatinine values (HR 1.5, CI 1.2-1.7) and New York Heart Association class (p=ns).Conclusion: B-lines are a simple user-friendly, bedside, sonographic sign of extravascular lung water, that provide useful information for the prognostic stratification in patients with heart failure and systolic dysfunction.