European Heart Journal - Cardiovascular Imaging (2022) 00, 1–4 HOW TO

https://doi.org/10.1093/ehjci/jeac239

How to assess systemic venous congestion

with point of care ultrasound

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1,2
Hatem Soliman-Aboumarie * and André Y. Denault3,4
1
Department of Anaesthetics and Cardiothoracic Critical Care, Harefield Hosputal, Hill End Road, Uxbridge, UB9 6JH London, UK; 2School of Cardiovascular and Metabolic Medicine and
Sciences, King’s College London, Denmark Hill, London SE5 9RS, UK; 3Anaesthetist and Intensivist, Institut de Cardiologie de Montreal, 5000 Rue Bélanger, Montréal QC H1T 1C8, Canada;
and 4Professeur titulaire de clinique, Directeur du programme de Fellowship en échographie ciblée, Département d’Anesthésiologie, Département de Pharmacologie, Affilié au département
de Médecine, Institut de Cardiologie de Montréal

Received 13 July 2022; accepted 16 November 2022

Introduction Assessment of the IVC

The systemic venous side of the circulation has long been forgotten as
an important component of the circulatory system. The concept of
Technique
preload responsiveness justified administration of large volumes of Sub-xyphoid or lateral transhepatic windows can be used to assess the
intravenous fluids; however, little was known about the implications IVC diameter either in the long axis and/or short axis positions approxi-
of excessive fluid administration on organ functions. As systemic venous mately 2 cm below the right atrial (RA) junction.
pressure increases, the perfusion pressure [mean arterial pressure–
right atrial pressure (RAP)] to the tissues can get compromised as it Interpretation
is the downstream pressure which the upstream pressure must over- Normal IVC diameter is <2.1 cm; therefore, it is very unlikely to have
come so that flow can be driven across the capillaries. Over the last systemic congestion with a non-dilated IVC.
years, a growing body of evidence showed that excessive fluid adminis-
tration is linked to increased incidence of acute kidney injury, increased
morbidity and mortality with multi-organ consequences. Pitfalls
In order to evaluate systemic venous congestion, variations of hepatic,
portal venous, and renal venous waveforms can be assessed to gain useful • Be wary of HC confluence (may overestimate IVC diameter).
information about venous congestion.1 For instance, portal hypertension • Do not mistake the IVC from the abdominal aorta (aorta has hypere-
due to cardiac disease could be considered a sonographic biomarker of choic wall and often pulsatile with every heartbeat).
right ventricular (RV) dysfunction (right ventriculo-arterial uncoupling). In
this article, we will describe the technique to assess venous congestion
• Athletes may have dilated IVC without elevated RAP, while those of ele-
vated intrabdominal pressure may have collapsed IVC despite elevated
using the Venous EXcess UltraSound (VExUS) score. The VeXUS score RAP.
is a four-staged validated protocol1 which evaluates the presence and se-
verity systemic venous congestion in the inferior vena cava (IVC) and or-
• IVC examination using a transverse and a longitudinal plane has shown a
better correlation with RAP.2,3
gans (liver, gut, and kidneys) by evaluating the IVC) diameter, venous
waveforms of the hepatic vein (HV), portal vein (PV), and interlobar renal
veins using colour Doppler (CD) and pulsed wave Doppler (PWD).
Portal hypertension due to cardiac disease could be considered a sono-
Assessment of the HVs
graphic biomarker of RV dysfunction (right ventriculo-arterial uncoup- Technique
ling). Portal hypertension is associated with worse outcomes after
The sub-xyphoid or lateral mid-axillary transhepatic windows can be
cardiac surgery.
used to assess the main HV as they drain into the IVC. Assessment
of HV is performed with CD and PWD. Slight downward tilt of the
transducer from the mid-axillary transhepatic window often enables
Preparation the visualization of the HV. PWD interrogation is performed at 1 cm
Examination of the patient is usually performed in the supine position. within the HV using CD to position the PWD sample volume.
A phased array (2–7.5 MHz) or curvilinear transducers (2–5 MHz) can
be used to evaluate the IVC, HV, PV, or renal veins. For HV and PVs
assessment, standard cardiac or abdominal can be equally used for scan- Interpretation
ning. For renal veins Doppler, reducing Nyquist limit below 10–15 cm/s There are three main HVs (right, middle, and left) which separate the
and increasing colour gain are often necessary as it may help revealing hepatic segments and lobes. HV appears thin walled on 2D and drains
the renal vessels. into the IVC. Color doppler of HV as it enters the IVC normally appears

* Corresponding author Tel: 00447873451401, E-mail: [email protected]

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: [email protected].
2 H. Soliman-Aboumarie and A.Y. Denault

‘blue’ as blood moves way from the transducer. PWD evaluation of the Pitfalls
HV is performed during quiet respiration or at end-expiratory hold
with the PWD sample volume on HV as it enters the IVC which de-
monstrates a waveform almost identical to the RAP waveform, and it • Slim subjects may have PV pulsatility without elevation of RA pressure.
gives important information about how the right heart is coping with • Doppler findings of congestion may be absent in liver cirrhosis or fatty
venous return. The normal HV waveform has one small retrograde liver.
wave due to atrial contraction ‘A wave’ and two antegrade waves dur- • Hepatic arterial flow (high impedance) can be seen at the background of
ing both systole ‘S wave’ and diastole ‘D wave’; during ventricular sys- PV flow.
tole, blood moves antegrade into the HV due to atrial relaxation, and

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during diastole, antegrade flow is caused by tricuspid valve opening. A
transitional retrograde wave ‘V wave’ between S and D waves could
be seen at the end of ventricular systole as the tricuspid annulus returns Assessment of the renal vessels
to its normal position increasing the RA pressure.
Normally, the S wave is larger than the D wave. With elevation of the Technique
RAP, S wave becomes smaller than the D wave and then with significant Flow in the intrarenal veins reflects the downstream effect of RAP on
increase in RAP, S wave reversal ensues (Figure 1). the encapsulated kidneys. The interlobar veins (located between the re-
A simultaneous electrocardiographic (ECG) tracing is essential to nal medullary pyramids) should be evaluated as they provide good
precisely identify the components of the hepatic venous waveform Doppler angles for interrogation. The hilar veins and the peripheral ar-
with A, S, and D waves occurring immediately after P, R, and T waves cuate veins should be avoided as they can either overestimate velocity
of the ECG waveforms, respectively. (in the former) or underestimate the velocity (in the latter). The kidney
is scanned in the lateral mid-axillary window at the 10th intercostal
space. In this position of the ultrasound probe in relation to the kidney,
Pitfalls most renal veins appear blue, and arteries appear red on CD. Reducing
Nyquist limit to < 10–15 cm/s and increasing colour gain may help re-
• The value of HV Doppler is limited in the presence of significant tricuspid
vealing the renal vessels.
regurgitation as S wave reversal may be present without significant sys-
temic venous congestion. Tricuspid valve incompetence will lead to
transmission of the RV systolic pressure to the right atrium, and depend-
ing on the degree of tricuspid valve incompetence, the systolic flow (S Interpretation
wave) may become reduced (S < D) or reversed (systolic reversal of Normal flow in the renal interlobar veins is monophasic during car-
hepatic venous flow). However, abnormal hepatic venous Doppler sig- diac cycle, and it appears below the baseline as the blood moves
nal can be observed without tricuspid regurgitation in RV dysfunction away from the transducer. Because of the narrow Doppler sampling
because of the absence of the annular motion. volume, renal arterial flow appears above the baseline which helps in
• HV waveform can be blunted in the following conditions: liver cirrhosis, identifying the phases of cardiac cycle. As RA pressure increases, the
renal venous flow becomes pulsatile, initially with distinct systolic (S)
fatty infiltration, hepatic lymphoma, Valsalva manoeuvre, abdominal
and diastolic (D) waves, and with further congestion, S wave be-
compartment, or IVC stenosis.
• Atrial fibrillation leads to loss of A wave and smaller S wave (S < D) even
comes reversed similar to what is seen with HV waveform; however,
because this reversed S wave becomes hidden by the arterial wave-
in the absence of elevated RA pressure.
form above the baseline, therefore an isolated diastolic (D-only)
waveform is seen. Those congestion patterns were associated with
worse outcomes in congestive heart failure and in cardiac surgery.
Assessment of the PVs Congestive renal failure could be seen as a consequence of congest-
ive heart failure and this phenotype could potentially lead to cardior-
Technique enal syndrome. Moreover, severe tricuspid regurgitation could also
The sub-xyphoid or lateral transhepatic windows can be used to assess lead to renal congestion with poor long-term prognosis in patients
the PV. Assessment of PV is performed with CD and PWD using a with heart failure.6
20 cm/s baseline velocity. Slight upward tilt of the transducer from the
mid-axillary transhepatic window often enables the visualization of the
PV. The main PV crosses over the IVC while the HV drains into it.
Pitfalls
Interpretation
PV walls are hyperechoic on 2D, and the flow appears ‘red’ on CD on • Technical difficulty is the major limitation of renal vessels Doppler be-
cause of the small vessels. Breath-holding helps if the patient can
the right PV from the mid-axillary position as blood moves towards the
cooperate.
transducer; however, the flow in PV branches may appear ‘blue’ in col-
our depending on their position relative to the transducer location. • Evaluation of hilar vessels could reveal a pulsatile pattern similar to the
In the absence of systemic venous congestion, PV flow shows no or HV pattern even without systemic venous congestion.
minimal variations (monophasic) which can be seen on CD as well as
PWD.4 During systemic venous congestion, pressure variations in the
right atrium during cardiac cycle get transmitted to the PV which leads VeXUS score
to portal venous pulsatility. This pulsatility can be quantified using the
PV pulsatility index (Vmax—Vmin/Vmax × 100%), where Vmax is the The VeXUS score1 was validated as a predictor of renal failure in car-
highest velocity and Vmin is the lowest velocity during cardiac cycle diac surgery. The parameters discussed in this document were the best
(Figure 1). PV pulsatility could be considered a sign of right heart dys- combined parameters which were found useful in predicting systemic
function, and it is associated with poor outcomes in right heart failure venous congestion (Figure 1). See Figure 1 for the details of VeXUS
patients.5 score.
 How to assess systemic venous congestion

Figure 1 (A) A schematic showing the VeXUS scanning protocol. (B) A table depicting various normal and abnormal VeXUS patterns and the scoring system.
3

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4 H. Soliman-Aboumarie and A.Y. Denault

Pitfalls in systemic venous utilized as fluid breaking points. Bedside assessment of haemodynamics
and fluid status should include a multi-modal ultrasound approach
congestion assessment which consists of echocardiography, lung ultrasound as well as ultra-
sound assessment of the systemic veins.
• Ultrasound for systemic venous assessment does not differentiate be- Conflicts of interest: H.S.-A.: speaker and consultancy honorarium
tween pressure and volume overload of the RV; therefore, ultrasound from EchoNous Inc. A.Y.D.: CAE-Healthcare (2010) speaker bureau,
information should be used within the clinical context and integrated (2020) KOL, Masimo (2017) speaker bureau, Edwards (2019) research
with other bedside information (clinical, laboratory, and imaging). (equipment grant) and supported by The Richard I. Kaufman
•

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In patients with long standing pulmonary hypertension with high VeXUS Endowment Fund in Anesthesia and Critical Care and Montreal
score, cautions should be taken to avoid aggressive offloading as the car- Heart Institute Foundation.
diac output in these patients may be dependent on high preload. Good
response to pulmonary vasodilators in the context of RV dysfunction
could be seen in somepatients as demonstrated by improvement in their
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