VExUS Nexus: Bedside Assessment of Venous Congestion

Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion. Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion. Clinical Summary•Backward transmission of elevated right atrial pressure causes abdominal organ congestion, which can lead to organ disfunction (congestive nephropathy).•Worsening degrees of congestion cause progressive alterations in organ venous flow that can be quantified using color Doppler.•This novel POCUS application enhances the classical physical examimation in patients with heart failure and provides useful information in addition to that conveyed by inferior vena cava and lung ultrasound. •Backward transmission of elevated right atrial pressure causes abdominal organ congestion, which can lead to organ disfunction (congestive nephropathy).•Worsening degrees of congestion cause progressive alterations in organ venous flow that can be quantified using color Doppler.•This novel POCUS application enhances the classical physical examimation in patients with heart failure and provides useful information in addition to that conveyed by inferior vena cava and lung ultrasound. A 47-year-old female with a past medical history of pulmonary arterial hypertension (group 1), severe tricuspid regurgitation and right ventricular (RV) dysfunction was referred to the emergency department with an increase in serum creatinine (0.71 to 2.3 mg/dL). She was recently seen in the pulmonary hypertension clinic where she was started on oral diuretics because of lower extremity edema. On interrogation, she feels fatigued but denies increased shortness of breath. Her medications include sildenafil, bosentan, furosemide, and spironolactone. Blood pressure was 89/62 mmHg with a heart rate of 96 bpm. Physical examination was notable for CV wave fusion on jugular venous pressure (JVP) examination, a holosystolic murmur at the left lower sternal border, and lower extremity edema. Capillary refill time was < 1 second. Urinalysis did not show proteinuria or hematuria with a specific gravity of 1.020. Urine sediment was bland and urinary sodium was 14 meq/L. Point-of-care ultrasonography revealed a normal lung ultrasound (A-Profile) and the inferior vena cava diameter was 2.7 cm with no respiratory variation. What would be the next step in the evaluation and management of this patient? Acute decompensated heart failure (ADHF) is characterized by hemodynamic derangements that include low cardiac output (“forward” failure) and elevated cardiac filling pressures (“backward” failure”).1Verbrugge F.H. Guazzi M. Testani J.M. Borlaug B.A. Altered hemodynamics and end-organ damage in heart failure: Impact on the lung and kidney.Circulation. 2020; 142: 998-1012Crossref PubMed Scopus (65) Google Scholar It is increasingly recognized that elevated filling pressures, rather than reduced cardiac output, is the primary hemodynamic factor driving kidney dysfunction and adverse outcomes in this patient population.2Mullens W. Abrahams Z. 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Certain conditions such as severe tricuspid regurgitation render JVP examination less useful.9Gheorghiade M. Follath F. Ponikowski P. et al.Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine.Eur J Heart Fail. 2010; 12: 423-433Crossref PubMed Scopus (502) Google Scholar Natriuretic peptides are secreted in response to increased wall tension caused by volume and pressure overload. However, they are of limited use given levels are influenced by several factors such as age, BMI, sepsis, pulmonary disease, and kidney dysfunction even in the absence of cardiac disease.10Kim Han-Na Januzzi James L. 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Systemic consequences of pulmonary hypertension and right-sided heart failure.Circulation. 2020; 141: 678-693Crossref PubMed Scopus (63) Google Scholar POCUS allows a semiquantitative assessment of RAP by evaluating the size and collapsibility index of the inferior vena cava (IVC).20Kircher B.J. Himelman R.B. Schiller N.B. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava.Am J Cardiol. 1990; 66: 493-496Abstract Full Text PDF PubMed Scopus (833) Google Scholar The short axis view to assess both the short and long diameter of the IVC has been shown to be a more reliable estimate of the central venous pressure (CVP).21Seo Y. Iida N. Yamamoto M. et al.Estimation of central venous pressure using the ratio of short to long diameter from Cross-Sectional images of the inferior vena cava.J Am Soc Echocardiogr. 2017; 30: 461-467Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Because of this, POCUS evaluation of the IVC can be used as a good starting point in the evaluation of abdominal venous congestion.22Beaubien-Souligny W. Rola P. Haycock K. et al.Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system.Ultrasound J. 2020; 12: 16-28Crossref PubMed Scopus (96) Google Scholar Organ dysfunction occurring with venous congestion is, however, not only related to increased RAP, but also to the transmission of pressure to the peripheral organs.4Jessup M. Costanzo M.R. The cardiorenal syndrome: do we need a change of strategy or a change of tactics?.J Am Coll Cardiol. 2009; 53: 597-599Crossref PubMed Scopus (98) Google Scholar Transmission of pressure alters the pattern of venous blood flow in a predictable way and these alterations can be quantified using venous Doppler.23Tang W.H.W. Kitai T. Intrarenal venous flow: a window into the congestive kidney failure Phenotype of heart failure?.JACC Heart Fail. 2016; 4: 683-686Crossref PubMed Scopus (56) Google Scholar,24Smith H.J. Grøttum P. Simonsen S. Ultrasonic assessment of abdominal venous return. II. Volume blood flow in the inferior vena cava and portal vein.Acta Radiol Diagn (Stockh). 1986; 27: 23-27Crossref PubMed Scopus (19) Google Scholar Thus, as opposed to other POCUS applications in the assessment of CHF, venous Doppler might allow an improved evaluation of congestive organ injury (Table 1).Table 1POCUS Assessment of Congestive Heart FailurePOCUS ParameterEvaluates Left-Sided CongestionEvaluates Right-Sided CongestionEvaluates Transmission of RAP to the OrgansJugular vein ultrasoundNoYesNoLung ultrasoundYesNoNoIVC ultrasoundNoYesNoPortal and intrarenal venous DopplerNoYesYesAbbreviations: POCUS, point-of-care ultrasound; RAP, right atrial pressure. Open table in a new tab Abbreviations: POCUS, point-of-care ultrasound; RAP, right atrial pressure. Normal blood flow in the central veins, including the hepatic veins (HVs), is pulsatile in nature. This pulsatility reflects the normal changes in RAP that occur with each cardiac cycle.25Reynolds T. Appleton C.P. Doppler flow velocity patterns of the superior vena cava, inferior vena cava, hepatic vein, coronary sinus, and atrial septal defect: a guide for the echocardiographer.J Am Soc Echocardiogr. 1991; 4: 503-512Abstract Full Text PDF PubMed Scopus (44) Google Scholar Because of the very distensible lumen of normal veins, blood flow pulsatility becomes attenuated within veins located farther away from the right atrium resulting in a continuous flow (Fig 1A).26Schroedter W.B. White J.M. Garcia A.R. Ellis M.E. Presence of lower-extremity venous pulsatility is not always the result of cardiac dysfunction.J Vasc Ultrasound. 2018; 38: 71-75Crossref Scopus (5) Google Scholar Similarly, normal venous blood flow in the portal vein and the renal interlobar veins is continuous or nonpulsatile (Fig 1B). When venous congestion is present, increased RAP and decreased venous wall distensibility augments the transmission of pressure causing blood flow to become pulsatile in distal veins (Fig 1C).27Klein H.O. Shachor D. Schneider N. David D. Unilateral pulsatile varicose veins from tricuspid regurgitation.Am J Cardiol. 1993; 71: 622-623Abstract Full Text PDF PubMed Scopus (17) Google Scholar,28Denault A.Y. Aldred M.P. Hammoud A. et al.Doppler interrogation of the femoral vein in the critically ill patient: the Fastest potential Acoustic window to Diagnose right ventricular dysfunction?.Crit Care Explor. 2020; 2e0209Crossref PubMed Google Scholar This is also the case for organ venous blood flow. Quantification of these flow alterations forms the basis of the POCUS assessment of venous congestion.23Tang W.H.W. Kitai T. Intrarenal venous flow: a window into the congestive kidney failure Phenotype of heart failure?.JACC Heart Fail. 2016; 4: 683-686Crossref PubMed Scopus (56) Google Scholar For hepatic and portal vein Doppler, the patient is positioned supine or in the left lateral decubitus position. Either a curvilinear or phased array probe can be used (2.5-5 MHz) which should be positioned in the mid to posterior axillary line to identify the liver vessels.29Beaubien-Souligny W. Benkreira A. Robillard P. et al.Alterations in portal vein flow and Intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective Observational cohort study.J Am Heart Assoc. 2018; 7e009961Crossref PubMed Scopus (79) Google Scholar The probe marker is directed toward the patient's head (Fig 2). Color Doppler imaging scale should be adjusted to low flow velocities (20-30 cm/s); this can also be achieved by selecting the abdominal preset on the ultrasound machine. The hepatic and portal veins are sampled with pulsed wave Doppler at the end of an expiratory hold while avoiding the Valsalva maneuver.30Abu-Yousef M.M. Normal and respiratory variations of the hepatic and portal venous duplex Doppler waveforms with simultaneous electrocardiographic correlation.J Ultrasound Med. 1992; 11: 263-268Crossref PubMed Scopus (96) Google Scholar Conventionally, blood flow directed toward the ultrasound probe will display a positive velocity while flow directed against the probe will display a negative velocity on the Doppler waveform.31Anavekar N.S. Oh J.K. Doppler echocardiography: a contemporary review.J Cardiol. 2009; 54: 347-358Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Simultaneous ECG recording allows the signal to be synchronized with the cardiac cycle. For the intrarenal venous Doppler, the probe is displaced caudally and posteriorly to render a longitudinal view of the kidney. Color Doppler imaging scale should be lowered further (less than 20 cm/s) and the interlobar veins should be identified. The best aligned interlobar vein should be sampled with pulsed wave Doppler at the end of an expiratory hold.32Pellicori P. Platz E. Dauw J. et al.Ultrasound imaging of congestion in heart failure: examinations beyond the heart.Eur J Heart Fail. 2021; 23: 703-712Crossref PubMed Scopus (50) Google Scholar HV are located in the immediate vicinity of the IVC; thus normal flow in the HV is pulsatile and mirrors changes in the CVP during the normal cardiac cycle (Fig 3A). The normal HV waveform is composed of two distinct antegrade waves (flow from the liver to the heart) and two retrograde waves (flow from the heart to the liver).25Reynolds T. Appleton C.P. Doppler flow velocity patterns of the superior vena cava, inferior vena cava, hepatic vein, coronary sinus, and atrial septal defect: a guide for the echocardiographer.J Am Soc Echocardiogr. 1991; 4: 503-512Abstract Full Text PDF PubMed Scopus (44) Google Scholar Because of the position of the ultrasound probe, antegrade waves display a negative velocity (flow away from the transducer) while retrograde waves display a positive velocity (flow toward the transducer). The normal antegrade waves are the “S” and “D” waves and occur during the “x” and “y” descents of CVP waveform, respectively; In normal subjects, “S” has a larger amplitude than “D”. The retrograde waves “A” and “V” correspond to the “a” and “v” waves on CVP waveform.33Scheinfeld M.H. Bilali A. Koenigsberg M. Understanding the spectral Doppler waveform of the hepatic veins in health and disease.Radiographics. 2009; 29: 2081-2098Crossref PubMed Scopus (104) Google Scholar Pathological alterations in right heart filling pattern can alter the HV waveform (Fig 3B). As RAP increases, the pressure gradient between the HVs and the RA decreases, thus lowering the forward systolic flow.34Nagueh S.F. Kopelen H.A. Zoghbi W.A. Relation of mean right atrial pressure to echocardiographic and Doppler parameters of right atrial and right ventricular function.Circulation. 1996; 93: 1160-1169Crossref PubMed Scopus (209) Google Scholar RV systolic dysfunction or tricuspid regurgitation can also result in decreased “S” wave amplitude or even “S” wave reversal in severe regurgitation. In addition, increased atrial volume with decreased compliance will produce large “A” and “V” waves typically seen in chronic pulmonary hypertension.35Zhang-An Himura Y. 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Kaihotsu K. et al.The clinical Impact of portal vein pulsatility on the Prognosis of hospitalized acute heart failure patients.J Am Coll Cardiol. 2020; 142: A14595Google Scholar In a recent prospective study of patients with ADHF, increased portal vein PF at discharge was closely associated with RV dysfunction and correlated with increased risk of mortality. However, the predictive value of altered portal flow was not superior to that of a clinical score of congestion.46Bouabdallaoui N. Beaubien-Souligny W. Oussaïd E. et al.Assessing Splanchnic compartment using portal venous Do