Pulmonary surfactant is a highly surface-active lipoprotein complex that lines the alveoli and terminal airways, reducing surface tension and preventing alveolar collapse at the end of expiration. It consists of a lipid (90%) and a protein fraction, with surfactant proteins SP-A, SP-B, SP-C, and SP-D playing crucial roles. SP-B is essential for surfactant function, and its absence leads to severe respiratory failure. Recent studies have shown that plasma SP-B levels are elevated in heart failure (HF) patients, likely due to increased pulmonary microvascular pressure and alveolar-capillary barrier dysfunction. SP-B correlates with HF severity and prognosis, outperforming functional parameters as a predictor of hospitalization. This study aims to compare surfactant proteins with other biomarkers, including RAGE, a receptor linked to lung injury. Using advanced multiplex mass spectrometry, the study seeks to validate immature SP-B as a reliable diagnostic and prognostic marker for HF.

Pulmonary surfactant is a highly surface-active lipoprotein complex that forms a thin film lining the alveolar and terminal airway surfaces. Its primary physiological function is to reduce surface tension at the air-liquid interface, stabilizing the alveoli and preventing their collapse at the end of expiration. Both the lipid and protein fractions of surfactant are synthesized by type II pneumocytes and stored in lamellar bodies-intracellular organelles where surfactant is secreted through the fusion of their outer membrane with the apical plasma membrane of the cell, releasing surfactant into the alveolar space.

The surface-active properties of pulmonary surfactant at the liquid-gas interface of the alveoli are primarily attributed to its lipid component (90%), particularly phospholipids. Although accounting for less than 10% of the surfactant, the protein fraction-composed of SP-A, SP-B, SP-C, and SP-D-plays a crucial role. SP-B, along with SP-C, is essential for the lipid fraction's ability to exert its surface-active function. The absence of SP-B is associated with severe respiratory failure, which can be fatal. SP-A and SP-D are less directly involved in surfactant's surface activity but appear to have significant anti-infective functions in the lungs.

Human SP-B is a small amphipathic peptide of 79 amino acids (8 kDa), produced through proteolytic processing from a 381-amino acid precursor (42 kDa). It is encoded by a single gene (SFTPB) located on chromosome 2. SP-B is predominantly produced by type II alveolar epithelial cells, initially synthesized as a glycosylated precursor that is transported from the endoplasmic reticulum to the Golgi apparatus, then to multivesicular bodies, and finally packaged into lamellar bodies. The proteolytic maturation of SP-B occurs during its transfer from multivesicular bodies to lamellar bodies, where active SP-B is stored together with SP-C and phospholipids. The contents of lamellar bodies are secreted into the airway space, where SP-A facilitates surfactant film formation over the alveolar surface.

Extracellular SP-B plays a fundamental role in surfactant homeostasis by promoting lipid absorption into the surface film and enhancing its stability during the compression and expansion cycles of respiration.

Recent studies have shown that in heart failure (HF) patients, plasma SP-B levels are significantly elevated, likely due to increased pulmonary microvascular pressure, which may compromise alveolar-capillary barrier integrity, leading to SP-B release into circulation. Plasma levels of immature SP-B, a surfactant protein isoform, increase in HF patients and strongly correlate with functional indicators of pulmonary impairment (peak oxygen uptake, VO2, lung diffusion, DLco) and New York Heart Association (NYHA) classification, establishing SP-B as a specific marker of disease severity linked to organ damage. More importantly, our studies indicate that SP-B is a circulating prognostic marker for hospitalization in HF patients, with superior predictive ability compared to functional parameters. Furthermore, SP-B also emerges as a marker of therapeutic efficacy.

Despite extensive research, the availability of diagnostic biomarkers for HF remains limited. In addition to natriuretic peptides, which vary under different pathological conditions and lack specificity for HF, a limited number of novel biomarkers have recently emerged, including interleukine ST2, Growth/differentiation factor 15 (GDF-15), Cystatin C, lipocalina-2 (NGAL), and Galectin-3.

Additionally, circulating levels of surfactant protein D (SP-D), which typically increase in pulmonary inflammation, asthma, emphysema, or chronic obstructive pulmonary disease (COPD), have been linked to cardiovascular disease and overall mortality in patients with coronary artery disease diagnosed via angiography. These associations appear independent of conventional risk factors such as age, smoking, cholesterol levels, and C-reactive protein.

This study aims to compare surfactant protein levels with previously described biomarkers and with RAGE (Receptor for Advanced Glycation End Products), a surface molecule belonging to the immunoglobulin superfamily. Unlike other receptors, RAGE is characterized by its multi-ligand nature, allowing interactions with various molecules involved in homeostasis, development, and inflammation. Recent findings indicate that RAGE levels are altered in pulmonary damage conditions such as sarcoidosis, pulmonary fibrosis, and chronic bronchitis, suggesting its potential role as an organ damage marker.

By employing advanced multiplexing methodology based on mass spectrometry, this study will validate the role of immature SP-B as a precise diagnostic and prognostic biomarker for heart failure.

Inclusion Criteria:

• Heart failure diagnosis
• Left ventricular ejection fraction <40%
• Stable clinical condition

Exclusion Criteria:

• Relevant comorbidities
• usual contraindications to cardiopulmonary testing.