Jean\u00a0Deschamps,\u00a0William\u00a0Beaubien-Souligny<\/h3>\n\n\n\nChest 2024; 165: 478-481<\/h3>\n\n\n\nhttps:\/\/doi.org\/10.1016\/j.chest.2023.11.007<\/a><\/h3>\n\n\n\nFor the last decade, inferior vena cava (IVC) measurements and variability have been the de facto noninvasive echocardiographic measurement to infer right-sided filling pressures and remain at the forefront of current echocardiography guidelines.1<\/sup><\/a>Despite extensive data that have questioned its accuracy, it remains a well-anchored practice in ICUs, inpatient wards, and echocardiography laboratories.2<\/sup><\/a> Notably, IVC size may be < 2 cm despite elevated cardiac filling pressures with abdominal hypertension, which is common in obesity, or in individuals with small body size for whom standardization to body surface area likely would be required, but seldom is implemented.3<\/sup><\/a>,<\/sup>4<\/sup><\/a> Although IVC respiratory size variation performs better, it is prone to inaccuracies related to variable respiratory efforts or high-pressure settings during positive pressure ventilation.5<\/sup><\/a> Furthermore, patients with precapillary pulmonary hypertension may have lower invasive right atrial pressures (RAP) than estimated by IVC size if the tricuspid valve is competent.6<\/sup><\/a><\/p>\n\n\n\nRecently, it was suggested that using pulse wave Doppler imaging in systemic veins, including hepatic, portal, and intrarenal veins, can identify abnormal waveforms that are the hallmark of a distended, noncompliant venous system.7<\/sup><\/a> The assessment of these venous Doppler anomalies at multiple sites has been coined the venous excess ultrasound (VExUS) assessment and assumes that the concomitant presence of multiple markers increases the likelihood that venous hypertension is present.<\/p>\n\n\n\nIn this issue of CHEST<\/em>, Longino et al8<\/sup><\/a> report the results of a prospective study aimed at analyzing the correlation between VExUS assessment and invasive measurements from right heart catheterization (RHC). The authors report a moderate to high correlation of VExUS with invasive RAP measurements. Most importantly, VExUS seems have a high ability to discriminate a high RAP (> 10 mm Hg), which was superior compared with IVC diameter or inspiratory collapsibility index. Practically speaking, the presence of at least one severely abnormal venous Doppler finding (grade \u2265 2) identified a RAP of > 10 mm Hg with a sensitivity of 0.90 and a specificity of 0.87, whereas the absence of any abnormal Doppler findings (grade \u2264 1) can identify a RAP of < 7 mm Hg with high sensitivity (0.95), but low specificity (0.56).<\/p>\n\n\n\nThis study is the first comparing VExUS with high-quality invasive RHC measurements and sheds important light and insights on its reliability as a noninvasive tool. Previous studies of VExUS have relied on bedside or operating room pulmonary artery catheterization, which are more prone to inaccurate measurements.9<\/sup><\/a> Older studies previously compared RHC measurements with individual components of the VExUS score.10<\/sup><\/a> However, these findings are in line with previous studies and cement it as a reliable, easily accessible, noninvasive marker of RAP that may be superior to the use of IVC measurements. Furthermore, this work supports VExUS as a promising tool for evaluating the severity of heart failure and monitoring decongestive therapy. In a subset of patients, Longino et al8<\/sup><\/a> showed improvement in VExUS grade in response to diuretic therapy, which reinforces previous findings in other cohorts of patients with acutely decompensated heart failure or ICU admission.11<\/sup><\/a>,<\/sup>12<\/sup><\/a> However, they were unable to demonstrate an improvement in VExUS grade and creatinine from time of RHC to discharge, in contrast with the same cohorts of patients.11<\/sup><\/a>,<\/sup>12<\/sup><\/a><\/p>\n\n\n\nDespite the impressive performance exhibited by the current VExUS classification to identify high RAP in the work by Longino et\u00a0al,8<\/sup><\/a>\u00a0it is probable that it could be mproved to yield even greater diagnostic accuracy. The current categorical VExUS gradation is based on predefined thresholds to categorize venous Doppler waveforms as abnormal by virtue of their association with adverse outcomes in cardiac surgery and heart failure cohorts. However, these abnormalities also can be quantified using continuous indexes.13<\/sup><\/a>\u00a0Because the pilot work from Longino et\u00a0al8<\/sup><\/a>\u00a0confirms the potential value of the VExUS assessment, collecting data from a larger cohort of patients could help to define optimal thresholds and combinations of venous Doppler markers to leverage the full potential of this assessment. We hope that this would go beyond the goal of identifying high RAP to detecting venous hypertension severe enough to be harmful to end organs, as evidenced by the association with acute kidney injury in the present study and in cardiac surgery. Because a plethoric IVC cannot not differentiate between moderately high and severely high venous pressure, this finding is common in the context of well-compensated heart failure with limited end-organ impact of systemic congestion. Decongestive therapy studies using VExUS may benefit from continuous variable assessment to identify an inflection point below which congestion no longer is contributing to ongoing kidney injury. This may be of interest in noncardiac populations in which the association of VExUS grade and acute kidney injury during decongestive therapy at times seems dissociated, likely because of acute tubular necrosis.12<\/sup><\/a>,<\/sup>14<\/sup><\/a>\u00a0Conversely, in patients with cardiorenal syndrome, a recent randomized controlled trial showed that VExUS-guided strategy may help to achieve optimal decongestion, likely through selecting patients for whom an intensification of diuretic therapy is appropriate.15<\/sup><\/a>\u00a0Given the recent emergence of this score, the current landscape of studies is heterogeneous in methodology and associations investigated (Table\u00a01<\/a>),7<\/sup><\/a>,<\/sup>8<\/sup><\/a>,<\/sup>11<\/sup><\/a>,<\/sup>12<\/sup><\/a>,<\/sup>14<\/sup><\/a>,<\/sup>15<\/sup><\/a>\u00a0and more consistent approaches across populations are needed to strengthen future research.<\/p>\n\n\n\n![\"\"](\"https:\/\/csccm.org.cn\/wp-content\/uploads\/2024\/03\/\u56fe\u7247-1-1024x457.png\")
<\/a><\/figure>\n\n\n\nVery few, if any, would argue that VExUS can or should replace invasive measurements as the most accurate index of increased RAP or right-sided congestion. However, we believe it fills an important gap: a practical, reliable, and easily accessible accurate measurement of RAP in populations in which invasive measurements are inaccessible or impractical. Although VExUS may help to nuance the impact of high filling pressures in ICU settings, we foresee that this tool can be useful specifically in non-ICU inpatient and outpatient settings such as internal medicine, nephrology, and cardiology services in the wake of the rapidly expanding availability of point-of-care ultrasound machines. In summary, VExUS appears to be positioned to replace IVC as the most readily and accurate tool outside of expert invasive measurements of RAP.<\/p>\n","protected":false},"excerpt":{"rendered":"
Editorial Venous Doppler for Echocardiographic Right At […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25674"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions"}],"predecessor-version":[{"id":25676,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions\/25676"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25674"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=25674"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=25674"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
https:\/\/doi.org\/10.1016\/j.chest.2023.11.007<\/a><\/h3>\n\n\n\nFor the last decade, inferior vena cava (IVC) measurements and variability have been the de facto noninvasive echocardiographic measurement to infer right-sided filling pressures and remain at the forefront of current echocardiography guidelines.1<\/sup><\/a>Despite extensive data that have questioned its accuracy, it remains a well-anchored practice in ICUs, inpatient wards, and echocardiography laboratories.2<\/sup><\/a> Notably, IVC size may be < 2 cm despite elevated cardiac filling pressures with abdominal hypertension, which is common in obesity, or in individuals with small body size for whom standardization to body surface area likely would be required, but seldom is implemented.3<\/sup><\/a>,<\/sup>4<\/sup><\/a> Although IVC respiratory size variation performs better, it is prone to inaccuracies related to variable respiratory efforts or high-pressure settings during positive pressure ventilation.5<\/sup><\/a> Furthermore, patients with precapillary pulmonary hypertension may have lower invasive right atrial pressures (RAP) than estimated by IVC size if the tricuspid valve is competent.6<\/sup><\/a><\/p>\n\n\n\nRecently, it was suggested that using pulse wave Doppler imaging in systemic veins, including hepatic, portal, and intrarenal veins, can identify abnormal waveforms that are the hallmark of a distended, noncompliant venous system.7<\/sup><\/a> The assessment of these venous Doppler anomalies at multiple sites has been coined the venous excess ultrasound (VExUS) assessment and assumes that the concomitant presence of multiple markers increases the likelihood that venous hypertension is present.<\/p>\n\n\n\nIn this issue of CHEST<\/em>, Longino et al8<\/sup><\/a> report the results of a prospective study aimed at analyzing the correlation between VExUS assessment and invasive measurements from right heart catheterization (RHC). The authors report a moderate to high correlation of VExUS with invasive RAP measurements. Most importantly, VExUS seems have a high ability to discriminate a high RAP (> 10 mm Hg), which was superior compared with IVC diameter or inspiratory collapsibility index. Practically speaking, the presence of at least one severely abnormal venous Doppler finding (grade \u2265 2) identified a RAP of > 10 mm Hg with a sensitivity of 0.90 and a specificity of 0.87, whereas the absence of any abnormal Doppler findings (grade \u2264 1) can identify a RAP of < 7 mm Hg with high sensitivity (0.95), but low specificity (0.56).<\/p>\n\n\n\nThis study is the first comparing VExUS with high-quality invasive RHC measurements and sheds important light and insights on its reliability as a noninvasive tool. Previous studies of VExUS have relied on bedside or operating room pulmonary artery catheterization, which are more prone to inaccurate measurements.9<\/sup><\/a> Older studies previously compared RHC measurements with individual components of the VExUS score.10<\/sup><\/a> However, these findings are in line with previous studies and cement it as a reliable, easily accessible, noninvasive marker of RAP that may be superior to the use of IVC measurements. Furthermore, this work supports VExUS as a promising tool for evaluating the severity of heart failure and monitoring decongestive therapy. In a subset of patients, Longino et al8<\/sup><\/a> showed improvement in VExUS grade in response to diuretic therapy, which reinforces previous findings in other cohorts of patients with acutely decompensated heart failure or ICU admission.11<\/sup><\/a>,<\/sup>12<\/sup><\/a> However, they were unable to demonstrate an improvement in VExUS grade and creatinine from time of RHC to discharge, in contrast with the same cohorts of patients.11<\/sup><\/a>,<\/sup>12<\/sup><\/a><\/p>\n\n\n\nDespite the impressive performance exhibited by the current VExUS classification to identify high RAP in the work by Longino et\u00a0al,8<\/sup><\/a>\u00a0it is probable that it could be mproved to yield even greater diagnostic accuracy. The current categorical VExUS gradation is based on predefined thresholds to categorize venous Doppler waveforms as abnormal by virtue of their association with adverse outcomes in cardiac surgery and heart failure cohorts. However, these abnormalities also can be quantified using continuous indexes.13<\/sup><\/a>\u00a0Because the pilot work from Longino et\u00a0al8<\/sup><\/a>\u00a0confirms the potential value of the VExUS assessment, collecting data from a larger cohort of patients could help to define optimal thresholds and combinations of venous Doppler markers to leverage the full potential of this assessment. We hope that this would go beyond the goal of identifying high RAP to detecting venous hypertension severe enough to be harmful to end organs, as evidenced by the association with acute kidney injury in the present study and in cardiac surgery. Because a plethoric IVC cannot not differentiate between moderately high and severely high venous pressure, this finding is common in the context of well-compensated heart failure with limited end-organ impact of systemic congestion. Decongestive therapy studies using VExUS may benefit from continuous variable assessment to identify an inflection point below which congestion no longer is contributing to ongoing kidney injury. This may be of interest in noncardiac populations in which the association of VExUS grade and acute kidney injury during decongestive therapy at times seems dissociated, likely because of acute tubular necrosis.12<\/sup><\/a>,<\/sup>14<\/sup><\/a>\u00a0Conversely, in patients with cardiorenal syndrome, a recent randomized controlled trial showed that VExUS-guided strategy may help to achieve optimal decongestion, likely through selecting patients for whom an intensification of diuretic therapy is appropriate.15<\/sup><\/a>\u00a0Given the recent emergence of this score, the current landscape of studies is heterogeneous in methodology and associations investigated (Table\u00a01<\/a>),7<\/sup><\/a>,<\/sup>8<\/sup><\/a>,<\/sup>11<\/sup><\/a>,<\/sup>12<\/sup><\/a>,<\/sup>14<\/sup><\/a>,<\/sup>15<\/sup><\/a>\u00a0and more consistent approaches across populations are needed to strengthen future research.<\/p>\n\n\n\n<\/a><\/figure>\n\n\n\nVery few, if any, would argue that VExUS can or should replace invasive measurements as the most accurate index of increased RAP or right-sided congestion. However, we believe it fills an important gap: a practical, reliable, and easily accessible accurate measurement of RAP in populations in which invasive measurements are inaccessible or impractical. Although VExUS may help to nuance the impact of high filling pressures in ICU settings, we foresee that this tool can be useful specifically in non-ICU inpatient and outpatient settings such as internal medicine, nephrology, and cardiology services in the wake of the rapidly expanding availability of point-of-care ultrasound machines. In summary, VExUS appears to be positioned to replace IVC as the most readily and accurate tool outside of expert invasive measurements of RAP.<\/p>\n","protected":false},"excerpt":{"rendered":"
Editorial Venous Doppler for Echocardiographic Right At […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25674"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions"}],"predecessor-version":[{"id":25676,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions\/25676"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25674"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=25674"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=25674"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
Recently, it was suggested that using pulse wave Doppler imaging in systemic veins, including hepatic, portal, and intrarenal veins, can identify abnormal waveforms that are the hallmark of a distended, noncompliant venous system.7<\/sup><\/a> The assessment of these venous Doppler anomalies at multiple sites has been coined the venous excess ultrasound (VExUS) assessment and assumes that the concomitant presence of multiple markers increases the likelihood that venous hypertension is present.<\/p>\n\n\n\n In this issue of CHEST<\/em>, Longino et al8<\/sup><\/a> report the results of a prospective study aimed at analyzing the correlation between VExUS assessment and invasive measurements from right heart catheterization (RHC). The authors report a moderate to high correlation of VExUS with invasive RAP measurements. Most importantly, VExUS seems have a high ability to discriminate a high RAP (> 10 mm Hg), which was superior compared with IVC diameter or inspiratory collapsibility index. Practically speaking, the presence of at least one severely abnormal venous Doppler finding (grade \u2265 2) identified a RAP of > 10 mm Hg with a sensitivity of 0.90 and a specificity of 0.87, whereas the absence of any abnormal Doppler findings (grade \u2264 1) can identify a RAP of < 7 mm Hg with high sensitivity (0.95), but low specificity (0.56).<\/p>\n\n\n\n This study is the first comparing VExUS with high-quality invasive RHC measurements and sheds important light and insights on its reliability as a noninvasive tool. Previous studies of VExUS have relied on bedside or operating room pulmonary artery catheterization, which are more prone to inaccurate measurements.9<\/sup><\/a> Older studies previously compared RHC measurements with individual components of the VExUS score.10<\/sup><\/a> However, these findings are in line with previous studies and cement it as a reliable, easily accessible, noninvasive marker of RAP that may be superior to the use of IVC measurements. Furthermore, this work supports VExUS as a promising tool for evaluating the severity of heart failure and monitoring decongestive therapy. In a subset of patients, Longino et al8<\/sup><\/a> showed improvement in VExUS grade in response to diuretic therapy, which reinforces previous findings in other cohorts of patients with acutely decompensated heart failure or ICU admission.11<\/sup><\/a>,<\/sup>12<\/sup><\/a> However, they were unable to demonstrate an improvement in VExUS grade and creatinine from time of RHC to discharge, in contrast with the same cohorts of patients.11<\/sup><\/a>,<\/sup>12<\/sup><\/a><\/p>\n\n\n\n Despite the impressive performance exhibited by the current VExUS classification to identify high RAP in the work by Longino et\u00a0al,8<\/sup><\/a>\u00a0it is probable that it could be mproved to yield even greater diagnostic accuracy. The current categorical VExUS gradation is based on predefined thresholds to categorize venous Doppler waveforms as abnormal by virtue of their association with adverse outcomes in cardiac surgery and heart failure cohorts. However, these abnormalities also can be quantified using continuous indexes.13<\/sup><\/a>\u00a0Because the pilot work from Longino et\u00a0al8<\/sup><\/a>\u00a0confirms the potential value of the VExUS assessment, collecting data from a larger cohort of patients could help to define optimal thresholds and combinations of venous Doppler markers to leverage the full potential of this assessment. We hope that this would go beyond the goal of identifying high RAP to detecting venous hypertension severe enough to be harmful to end organs, as evidenced by the association with acute kidney injury in the present study and in cardiac surgery. Because a plethoric IVC cannot not differentiate between moderately high and severely high venous pressure, this finding is common in the context of well-compensated heart failure with limited end-organ impact of systemic congestion. Decongestive therapy studies using VExUS may benefit from continuous variable assessment to identify an inflection point below which congestion no longer is contributing to ongoing kidney injury. This may be of interest in noncardiac populations in which the association of VExUS grade and acute kidney injury during decongestive therapy at times seems dissociated, likely because of acute tubular necrosis.12<\/sup><\/a>,<\/sup>14<\/sup><\/a>\u00a0Conversely, in patients with cardiorenal syndrome, a recent randomized controlled trial showed that VExUS-guided strategy may help to achieve optimal decongestion, likely through selecting patients for whom an intensification of diuretic therapy is appropriate.15<\/sup><\/a>\u00a0Given the recent emergence of this score, the current landscape of studies is heterogeneous in methodology and associations investigated (Table\u00a01<\/a>),7<\/sup><\/a>,<\/sup>8<\/sup><\/a>,<\/sup>11<\/sup><\/a>,<\/sup>12<\/sup><\/a>,<\/sup>14<\/sup><\/a>,<\/sup>15<\/sup><\/a>\u00a0and more consistent approaches across populations are needed to strengthen future research.<\/p>\n\n\n\n Very few, if any, would argue that VExUS can or should replace invasive measurements as the most accurate index of increased RAP or right-sided congestion. However, we believe it fills an important gap: a practical, reliable, and easily accessible accurate measurement of RAP in populations in which invasive measurements are inaccessible or impractical. Although VExUS may help to nuance the impact of high filling pressures in ICU settings, we foresee that this tool can be useful specifically in non-ICU inpatient and outpatient settings such as internal medicine, nephrology, and cardiology services in the wake of the rapidly expanding availability of point-of-care ultrasound machines. In summary, VExUS appears to be positioned to replace IVC as the most readily and accurate tool outside of expert invasive measurements of RAP.<\/p>\n","protected":false},"excerpt":{"rendered":" Editorial Venous Doppler for Echocardiographic Right At […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=25674"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions"}],"predecessor-version":[{"id":25676,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/25674\/revisions\/25676"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=25674"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=25674"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=25674"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}<\/a><\/figure>\n\n\n\n