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Background Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis (TT) is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. Purpose In order to elucidate safety of lung ultrasound-driven TT in refractory heart failure, we compared incidence of pneumothorax requiring surgical drainage in patients undergoing TT with or without lung ultrasound. Methods and results In a single-centre retrospective analysis we recruited 373 patients with heart failure with reduced ejection fraction (26 ± 12%), New York Heart Association class ≥3, and pleural effusion ≥ moderate at lung ultrasound. They underwent overall 493 TT. Evacuated pleural fluid by passive drainage was 1030 ± 534 mL. The maximal interpleural space was 73.6 ± 15.6 mm before, and 12.4 ± 3.1 mm after TT (p &amp;lt; .001). Two groups of TT were identified ex-post: 462 guided by lung ultrasound (Group 1); 31 without ultrasound guidance (Group 2), performed by cardiologist/pneumologist lacking access to ultrasound machine or expertise in lung ultrasound). The rate of complications (pneumothorax) was 0/462 in Group 1 and 3/31 in Group 2 (0 vs 10%, p &amp;lt; 0.001) Conclusion Lung ultrasound-driven TT of pleural effusion in decompensated heart failure patients is feasible and safe when performed by cardiologists guided by lung ultrasound. A blind TT without ultrasound guidance is associated with higher rate of pneumothorax, and should be avoided.

P1431 Safety of thoracentesis in patients with refractory heart failure: lung ultrasound guidance is obligatory and blind procedures are not justified