Inferior Vena Cava Diameter Research Articles

Soluble Suppression of Tumorigenicity 2 (sST2) in Patients with Predominantly Decompensated Right Heart Failure—A Prospective Observational Study

Right heart failure is a major challenge in clinical practice. Soluble Suppression of Tumorigenicity-2 (sST2), a member of the interleukin-1-receptor family, may have clinical prognostic value. The aim of this study was to analyze whether sST2 correlates with signs of acute right heart decompensation. This prospective single-center study included 50 patients admitted for clinical signs of predominant right heart decompensation. Signs of reduced blood supply to other organs (e.g., renal function parameter, troponin T, NT-proBNP), diuretics, and signs of venous congestion (inferior vena cava (IVC) diameter) with fluid retention (weight gain, peripheral edema) resulting from reduced RV function were analyzed. The degree of peripheral edema was defined as none, mild (5–6 mm depressible, regression in 15–60 s) or severe (>7 mm depressible, regression in 2–3 min). sST2 levels were measured at the day of hospitalization. A total of 78.7% showed severe peripheral edema. The median concentration of sST2 was 35.2 ng/mL (25.–75. percentiles 17.2–46.7). sST2 is correlated with the peripheral edema degree (rSpearman = 0.427, p = 0.004) and the diameter of IVC (r = 0.786, p = 0.036), while NT-proBNP (r = 0.114, p = 0.456), troponin T (r = 0.123, p = 0.430), creatinine-based eGFR (r = −0.207, p = 0.195), or cystatin C-based eGFR (r = −0.032, p = 0.839) did not. sST2, but no other established marker, is correlated with peripheral and central fluid status in patients with decompensated right heart failure.

Ultrasonographic measurements of the inferior vena cava diameter in newborns: is it a useful tool for choosing an umbilical venous catheter?

The primary outcomes of this study were to evaluate the diameters of the inferior vena cava (IVC) in a cohort of newborns and the correlation between newborn weight and IVC diameter. The secondary outcome was to evaluate the concordance between the measurements performed by the two investigators. Two blind examiners performed an ultrasonographic (US) evaluation of the IVC diameter in neonates with a weight ranging from 2 to 4 kg. The exclusion criteria included hemodynamic instability, known vascular malformations, and major congenital malformations. A total of 143 neonates were enrolled between June 2019 and January 2021. All the US examinations were performed in the first 3 days of life. After dividing the patients into two groups according to their weight at the time of examination (2.0-2.99 kg and 3.0-4.0 kg), the median IVC diameters measured by examiner 1 were 3.1 mm (interquartile range 2.8-3.4) and 3.4 mm (interquartile range 2.9-3.8) (p = 0.003) for the two groups, respectively. The median IVC diameters measured by examiner 2 were 3.1 mm (interquartile range 2.6-3.3) and 3.3 mm (interquartile range 2.8-3.8) (p = 0.004) for the two groups, respectively. The intraclass correlation coefficient was 0.93 (95% CI: 0.90-0.95). The IVC diameter values varied widely from 1.2 to 5.2 mm in newborns weighing 2-4 kg, and a low correlation between newborn weight and IVC diameter was found, so measuring IVC diameter may be a recommended step prior to inserting a umbilical venous catheter (UVC). The concordance between operators was good. We contemplated that the IVC diameter could be a potentially useful tool to identify the most appropriate UVC, thus reducing the risk of catheter-related thrombosis.

Inferior vena cava and lung ultrasound-guided therapy in acute heart failure (CAVAL US-AHF study): a randomized controlled trial

Abstract Background The 90-day readmission rate for hospitalized patients with acute heart failure (AHF) ranges from 25% to 30%, mostly due to persistent congestion at discharge. Since the optimal assessment of decongestion has not been clearly defined, there is an opportunity to implement new tools to identify subclinical congestion to guide treatment. Purpose To evaluate whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US)-guided therapy in patients with AHF reduces subclinical congestion at discharge. A secondary objective was to investigate whether CAVAL US-guided therapy leads to improved outcomes al 90 days. Methods In this single-center, single-blind, randomized controlled trial, adult patients with AHF were randomized within 24 hours of hospital admission to the CAVAL US-guided strategy or clinically-guided decongestive therapy. A quantitative ultrasound protocol was used and patients were stratified into 3 groups according to the degree of congestion. All patients underwent lung and IVC ultrasound and were blinded to group allocation. The treating medical team was blinded to the results of the ultrasound evaluation in the control group and adjusted the treatments in the intervention group according to an individualized therapeutic algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter with and without collapsibility at discharge. The secondary endpoints were the composite of HF readmission, unplanned visit for worsening HF or death at 90 days and pro-B-type natriuretic peptide (NT-proBNP) reduction at discharge in %. Results Sixty patients were randomized to CAVAL US (n=30) or control (n=30). The mean age was 76.7±13 years, 68.3% were male and the mean left ventricular ejection fraction was 44% ± 15. The primary outcome occurred in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (p<.001). A reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank p=0.038). Other secondary endpoints such as NT-proBNP reduction at discharge showed a non-statistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; p=0.09). The mean hospital stay was 4.5±5 days in the CAVAL US group and 3.3±1.6 days in the control group (p=0.26), with a trend toward higher total furosemide use in the CAVAL US group (170 mg IQR 120-240 vs 120 mg IQR 80-200, p=0.08). Safety outcomes were similar in both groups (p>0.05). Conclusion IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides evidence for the use of a simple, safe and non-invasive technique to guide decongestive therapy during hospitalization for AHF, that reduced the risk of HF readmission, unplanned visit for worsening HF, or death at 90 days without prolonging hospital stay.Subclinical congestion at dischargeKM secondary endpoint

Hepatic venous stasis index reflects hepatic congestion and predicts adverse outcomes in patients with heart failure

Abstract Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in heart failure (HF) patients. However, the parameter which quantifies hepatic vein waveforms has not been established. We suggest hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in HF patients, we aimed to clarify the associations of HVSI with parameters of cardiac function and right heart catheterization (RHC), as well as that with prognosis, in patients with HF. Methods We performed abdominal ultrasonography, echocardiography and RHC in patients with HF (N = 513). The patients were divided into three groups based on HVSI as follows; HVSI 0 (HVSI = 0, N = 253), low HVSI (HVSI 0.01–0.20, N = 132) and high HVSI (HVSI > 0.20, N = 128) as shown in Figure 1. We examined the associations of HVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF. Results There were significant correlations between HVSI and mean right atrial pressure (R = 0.244, P < 0.001), right ventricular fractional area change (R = -0.195, P < 0.001) and inferior vena cava diameter (R = 0.318, P < 0.001). During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan–Meier analysis, cardiac event rate increased across increasing HVSI (log-lank, P = 0.002, Figure 2). In the multivariate Cox proportional hazard analysis, high HVSI was independently associated with cardiac events (high HVSI group vs. HVSI 0 group: hazard ratio, 1.746; 95% confidence interval, 1.053–2.894, P = 0.031). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF, and is associated with adverse prognosis in HF patients.Figure 1Figure 2

Association of CA-125 with markers of congestion, and effect of empagliflozin on CA-125 in patients with type 2 diabetes, or prediabetes, and heart failure with reduced ejection fraction (SUGAR-DM-HF)

Abstract Background Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of heart failure hospitalisation and cardiovascular death in patients with heart failure and reduced ejection fraction (HFrEF). However, their effects on carbohydrate antigen 125 (CA-125) are uncertain. CA-125 has a potential role in HFrEF in the assessment of congestion, guiding decongestive therapies, and predicting outcome. Purpose This exploratory biomarker substudy of the SUGAR-DM-HF trial investigated the relationship of CA-125 levels with markers of congestion, and the effect of the SGLT2 inhibitor empagliflozin on serum CA-125 levels. Methods We conducted a multicentre, randomised, double-blind, placebo-controlled trial investigating the effects of empagliflozin in patients with New York Heart Association functional class II-IV, left ventricular ejection fraction (LVEF) ≤40%, and type 2 diabetes or prediabetes.[1] Patients were randomly assigned 1:1 to empagliflozin 10mg daily or placebo. Blood biomarker samples were collected at baseline, weeks 12 and 36. Other measures of congestion assessed included cardiovascular magnetic resonance (CMR), kidney magnetic resonance imaging (MRI), transthoracic echocardiography (TTE), lung ultrasound (LUS), and bioelectrical impedance analysis (BIA). Results Among 105 patients [mean age 68.7 (SD, 11.1) years, 77 (73.3%) male, 82 (78.1%) diabetes and 23 (21.9%) prediabetes, mean LVEF 32.5% (9.8%)], median [IQR] CA-125 was 11.2 [8.9-17.6] U/mL. At baseline, those with higher CA-125 had a longer duration of diabetes, higher heart rate, lower LVEF, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP), were more likely to have a pleural effusion and be on a loop diuretic, but serum creatinine was similar. At baseline, CA-125 levels weakly correlated with NT-proBNP, the presence of a pleural effusion, number of B-lines, inferior vena cava (IVC) diameter, tricuspid regurgitation velocity, E/e’ average, apparent extracellular volume (aECV) of the right whole kidney,[2] and total body water (FIGURE 1). CA-125 levels were not significantly different between groups at week 12 or 36 (FIGURE 2). The beneficial effect of empagliflozin on reducing left ventricular end-systolic volume index (LVESVi) was not modified by baseline CA-125 (p interaction = 0.93). Change in CA-125 was not associated with change in the co-primary outcomes (LVESVi and left ventricular global longitudinal strain) at week 36, nor with change in NT-proBNP or change in body weight at week 12 or 36. Conclusion Among patients with HFrEF, CA-125 levels were not strongly associated with markers of congestion assessed with CMR, kidney MRI, TTE, LUS and BIA. CA-125 levels were not different between groups at week 12 or 36, although this trial was not powered for this outcome.Correlation heatmap (Spearman’s rho).Change in CA-125 levels.

Coronary sinus diameter to estimate congestion and predict survival

BackgroundCongestion predicts a poor prognosis, but its assessment is challenging in clinical practice and requires a multiparametric approach. We investigated if the coronary sinus (CS) diameter can predict mortality in a human model of rapid fluid unloading. MethodsWe measured by echocardiography the CS, and the inferior vena cava (IVC) for comparison, in 60 patients with end-stage chronic kidney disease (ESKD) immediately before and after hemodialysis (HD; age 76 [57–81] years, 40% female, left ventricular ejection fraction 57 [53–56]%). Patients were prospectively followed up for all-cause mortality. ResultsHD-induced decongestion decreased the maximum diameters of both CS and IVC (p ≤ 0.001 for all). The maximum diameter of the CS (CSmax) was as accurate as the IVC maximum diameter and collapsibility for the identification of congestion, defined as pre-hemodialysis status (AUROC CSmax = 0.902 vs IVC = 0.895, p = n.s.). A CSmax diameter after hemodialysis > 9 mm predicted all-cause mortality at 12 months (Log-rank Chi square = 11.49, p < 0.001). ConclusionsA persistently dilated CS after hemodialysis is a marker of residual congestion and predicts death at one year in high-risk ESKD patients.

Abstract 13612: Association Between B-Type Natriuretic Peptide and Inferior Vena Cava Diameter as a Measure of Hypovolemia in Cancer Patients

Introduction: Hypovolemia is frequently seen in cancer patients due to catabolism, cachexia, and decreased oral intake. However, volume status assessment in this population is often difficult due to competing comorbid conditions such as edema. Elevated B-type natriuretic peptide (BNP) is an established biomarker of myocardial wall stress in patients with hypervolemia. We sought to determine if very low BNP could be an objective marker of hypovolemia in cancer patients Hypothesis: In cancer patients undergoing treatment, is low BNP level (&lt;10 pg/mL) associated with small inferior vena cava (IVC) diameter (&lt; 1.4 cm) - an established marker of hypovolemia on transthoracic echocardiography (TTE)?We hypothesize that BNP &lt;10 pg/mL is associated with small IVC as a marker of hypovolemia in cancer patients. Methods: We conducted a retrospective study (N=91) with solid malignancies, undergoing chemo- and/or radiation therapy (RT), divided into 3 groups based on BNP values in pg/mL: low (BNP &lt;10), normal (BNP 10-100) and high (BNP&gt;100). Retrospective data were obtained between 2016-2023 from Rush University Medical Center Cardio-Oncology Registry. IVC measurements by 2 medial trainees (Cohen’s intraclass correlation coefficient = 0.87, p &lt; 0.01) were acquired from formal TTEs obtained within 1 week of BNP measurements. Linear regression was used to calculate the adjusted means (for age, sex, BMI, blood pressure, creatinine, RT, TSH) of the 2 measured IVC diameters per datapoint. Mean difference in IVC diameters was compared between the 3 BNP groups. Results: The population mean age was 59.99 ± 12.19, 67% women. Adjusted mean IVC measurements were 1.89cm, 1.55cm, and 1.26cm for the high, normal, and low BNP groups respectively. The mean difference in IVC diameters between high and low BNP groups was 0.628 ±0.164 cm (p&lt;0.01). Conclusions: In cancer patients undergoing treatment, very low BNP (&lt;10pg/mL) was associated with small IVC as a marker of hypovolemia. In this group of patients, BNP measured with routine lab data is a readily available tool to identify individuals with hypovolemia where other measures of volume status such as physical exams might be uncertain.

Abstract 12727: Liver Elasticity in Elderly Heart Failure Patient

Introduction: Liver elastography is a novel ultrasound technique assessing elasticity of liver tissue. Clinical indication of liver elastography remains unrevealed. Moreover, reports about relationship between liver stiffness and heart failure subtypes haven’t well been published. Hypothesis: We have investigated the cardio-hepatic interaction using liver elastography in heart failure subtypes. Methods: We prospectively enrolled 58 consecutive patients with heart failure admission from April 2022 to March 2023. Liver elastography, transthoracic echocardiography and blood sampling were done at the time of discharge from heart failure treatment. Results: Patients were divided into two groups according to the left ventricular ejection fraction (LVEF) of echocardiography: heart failure with reduced ejection fraction (HFrEF) group (EF ≦40%, n = 11) and non-HFrEF group (EF &gt;40%, n = 31). The mean age of all patients was 83 ± 11 years. The mean age and the prevalence of hypertension and diabetes mellitus was higher in non-HFrEF group than in HFrEF group. The prevalence of taking sodium glucose co-transporter 2 (SGLT2) inhibitors was lower in non-HFrEF group than in HFrEF group. LV end-diastolic diameter, LV end-systolic diameter was larger in HFrEF group than in non-HFrEF group. Tricuspid regurgitation pressure gradient (TRPG) was higher in non-HFrEF group than in HFrEF group. Inferior vena cava diameter was not different between two groups. The mean values of almost liver function tests of all patients were within the normal range. eGFR was lower in non-HFrEF group than in HFrEF group. Liver elasticity was higher in non-HFrEF group than in HFrEF group (7.1 ± 2.7 vs. 5.1 ± 1.5 hPa; P=0.008) indicating liver stiffness. Pearson’s correlation coefficient showed that liver elasticity was positively correlated with the prevalence of diabetes mellitus, LVEF, TRPG, serum creatinine, aspartate aminotransferase, γ-glutamyl transpeptidase and was negatively correlated with LV end-diastolic diameter, LV end-systolic diameter. Conclusions: Liver stiffness was elevated in EF-preserved heart failure patients. Liver elasticity was correlated with parameters of congestion (TRPG) and useful for the assessment of congestion in patients with heart failure.

Recurrent Leg Deep Vein Thrombosis in a Female with Atypical Right-Sided Variant of May Thurner Syndrome and Factor V Leiden Mutation

I ntroduction: May-Thurner syndrome (MTS) is a condition in which the right common iliac artery presses on the left common iliac vein, causing it to narrow over time. Right-sided MTS is a rare event. We present this unique case of recurrent right leg deep vein thrombosis in a female with atypical right sided variant of MTS and Factor V Leiden mutation. Case Presentation: A 34-year-old lady with with no signficiant past medical history presented to the hospital with right lower leg edema, tingling, and discolouration. She was taking oral contraceptive pills. Vitals were unremarkable. Doppler studies revealed right lower extremity deep vein thrombosis in the right external iliac vein, common iliac vein and common femoral vein. She was started on an intravenous heparin drip and subsequently had a thrombectomy procedure. She was subsequently discharged home on apixaban anticoagulation. We opted to request a hypercoagulable and vasculitis workup in light of the extensive thrombosis, despite the OCP risk factor, and discovered a heterozygous Factor V Leiden mutation. She returned to the hospital 2 days later with worsening right leg pain. Repeat Doppler studies demonstrated acute right femoral and popliteal deep vein thrombosis. CT angiography of abdomen and pelvis revealed significant right femoral vein DVT that extends into the External iliac vein, common iliac vein, and IVC to at least slightly below renal vein level. Invasive Radiology was consulted and she had a venogram and intravascular ultrasound (IVUS) which showed high-grade right common iliac vein and IVC stenosis (&amp;gt;90%) at L4 superior endplate. Iliac stenting and angioplasty improved iliac and inferior IVC diameters. Patient also underwent thrombectomy &amp; IVC filter placement. The diagnostic venography revealed a popliteal-to-proximal femoral vein rethrombosis. This was treated with tissue plasminogen activator (TPA) by 8 French power pulse AngioJet and a mechanical thrombectomy. This resulted in partial clearing of the common femoral vein with persistent narrowing and thrombosis of the popliteal vein. TPA was infused at 1 mg/hour with a 5 French McNamara lysis catheter over the popliteal region.Patient transferred to ICU for overnight intravenous thrombolysis. The patient was then re-initiated on the heparin drip and then bridged to therapeutic warfarin. Discussion: MTS is a phenomenon commonly described as an acquired stenosis of the left common iliac vein secondary to compression by the right common iliac artery 1. It has been associated with genetic clotting factor abnormalities, repeated pregnancies, postpartum, contraceptive pills, prolonged immobilization, scoliosis, anti-phospholipid syndrome, COVID-19, and recurrent DVT 2. In patients with left lower-limb DVT, the incidence of MTS is about 20-50%. Right lower limb DVT in patients with right sided variant of MTS is rare. Right lower limb DVT with right sided variant of MTS with co-existing Factor V Leiden mutation is even rarer. Ultrasound imaging typically cannot detect the high pelvic abnormalities seen in MTS. Contrast venography, MRI, or IVUS are needed to diagnose MTS 4. As was the case in our patient, venography should be done to evaluate stenosis and iliac vein compression hemodynamics after thrombus removal. Treatment of MTS depends on the presentation, severity of symptoms, and whether the patient has developed DVT. Conservative treatment such as compression stockings can be used for patients who are asymptomatic or have mild symptoms. For patients with moderate symptoms or DVT, endovascular treatment with stenting is recommended 5. Conclusion: This is a very atypical presentation of MTS variation affecting the right lower extremity with limited description in the literature. To our knowledge, this is the first case presentation of right sided MTS resulting in a DVT in a patient with factor V Leiden mutation. MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this disease entity is essential for early diagnosis and treatment.

Utility of VExUS score in the peri-operative care unit, intensive care unit, and emergency setting - A systematic review.

The venous excess ultrasound (VExUS) score presents a prospect of valuable clinical utility. The study aimed to systematically review the effectiveness of the VExUS score in detecting venous congestion across emergency, critical care, and peri-operative contexts; assessing its utility in improved patient outcomes; and exploring its relationship with established parameters. This systematic review was registered in the International Prospective Register of Systematic Reviews (CRD42023421034). A comprehensive literature search, employing pre-defined search terms related to the VExUS score in diverse clinical contexts, was conducted on articles published between 2000 and 15 May 2023 across databases- PubMed, PubMed Central, Cochrane, Scopus, Elsevier Clinical Key, and Google Scholar. Bias risk assessment was carried out using the Risk of Bias in Non-Randomised Studies tool. Given the significant heterogeneity across studies concerning participants, interventions, outcomes, and study designs, data pooling for a meaningful meta-analysis was not feasible. The review included 15 articles comprising observational studies, case series, and case reports. Most patients exhibited moderate-to-severe venous congestion based on their baseline VExUS scores. Higher VExUS scores correlated with a greater risk of acute kidney injury (AKI) in post-operative patients. The VExUS score strongly correlated with central venous pressure; specific components, such as the intra-renal monophasic pattern, portal-pulsatility, and inferior vena cava diameter, exhibited robust predictive value for venous congestion. VExUS score is valuable in assessing and predicting venous congestion, especially regarding AKI prediction risk and guiding interventions. However, its utility in predicting outcomes in acute heart failure patients appears less certain.

The War Against Heart Failure Hospitalizations: Remote Monitoring and the Case for Expanding Criteria.

Successful remote patient monitoring depends on bidirectional interaction between patients and multidisciplinary clinical teams. Invasive pulmonary artery pressure monitoring has been shown to reduce heart failure (HF) hospitalizations, facilitate guideline-directed medical therapy optimization, and improve quality of life. Cardiac implantable electronic device-based multiparameter monitoring has shown encouraging results in predicting future HF-related events. Potential expanded indications for remote monitoring include guideline-directed medical therapy optimization, application to specific populations, and subclinical detection of HF. Voice analysis, inferior vena cava diameter monitoring, and artificial intelligence-based remote electrocardiogram show potential to gain some merit in remote patient monitoring in HF.

The Use of Inferior Vena Cava Ultrasonography to Assess Fluid Overload in Acute Lung Oedema in Severe Preeclampsia Patient

Introduction: Accurate evaluation of volume status is essential for appropriate therapy because inadequate assessment of volume status can result in unnecessary administration of therapy, which can increase mortality. This study aimed to describe the use of inferior vena cava ultrasound in assessing fluid overload in severe preeclampsia patients.&#x0D; Case presentation: We report a 23-year-old female patient with a diagnosis of acute pulmonary oedema, and severe preeclampsia at G1P0A0 40 weeks gestation with complaints of shortness of breath. On physical examination, the patient appeared short of breath with RR 32 x/minute, fine wet crackles in both lung fields, SpO2 92% with NRM 15 L/m, HR 160 x/minute, lifting strength, CRT &lt; 2 seconds, blood pressure 160/120 mmHg. This patient underwent emergency termination of pregnancy by C-section under general anesthesia rapid sequence induction followed by intensive care in the ICU. Management in the ICU this patient was given mechanical ventilation, midazolam sedation 0.05 mg/kg, analgesic morphine 10 mcg/kg, fluid restriction with a fluid balance target of (-)1000 ml/24 hours and given furosemide 10 mg/hour to reduce fluid overload so that fluid in the lungs can be reduced. Evaluation of fluid overload by IVC ultrasound.&#x0D; Conclusion: Acute pulmonary edema requires proper management to get a good outcome. Measurement of the diameter of the inferior vena cava (IVC) can also be used to assess fluid volume status. Lack of volume is assessed with an IVC diameter of &lt;1.5 cm, while an IVC diameter of &gt;2.5 cm indicates volume overload.

Dynamic changes in echocardiographic parameters in acute decompensated heart failure: REALITY-ECHO

BackgroundAppropriate evaluation of hemodynamic status is vital in the management of acute heart failure (AHF). We aimed to investigate the changes in echocardiographic parameters during very acute phases of AHF and their association with clinical outcomes. MethodsPatients who were admitted to four Japanese hospitals with AHF were prospectively enrolled. Comprehensive echocardiography and B-type natriuretic peptide (BNP) were assessed both on admission and the second day. ResultsA total of 271 patients (80 ± 12 years old, 52 % male) was included. Overall, transmitral E velocity, E/A, tricuspid regurgitation pressure gradient (TRPG), and inferior vena cava diameter significantly decreased, and stroke volume and left ventricular ejection fraction showed a significant increase by the second day, whereas E/e′ did not change. On the second day, BNP increased in 50 patients (18 %). Despite similar baseline characteristics, patients with increased BNP showed a significantly smaller improvement in transmitral flow parameters (E and A velocity, E/A, and flow patterns) and a smaller decrease in TRPG compared with patients with decreased BNP. Other echocardiographic parameter changes were not different between the groups. A combination of improvement in transmitral flow and TRPG was significantly associated with 90-day and 1-year composite events of all-cause death and heart failure hospitalization after adjustment by the Get With the Guidelines-Heart Failure risk score. ConclusionsEchocardiographic parameters show a dynamic change in the very acute phase of AHF. Several parameters, such as the transmitral flow and TRPG might be useful in monitoring favorable hemodynamic change.

The First Ever Robotic-Assisted Laparoscopic Radical Nephrectomy with Inferior Vena Cava Thrombectomy Performed in Thailand: A Case Report of Atypical Presentation of Urothelial Carcinoma with Tumor Thrombus

Background: Robotic-assisted surgery was proposed as an alternative to open surgery for management of inferior vena cava (IVC) thrombus together with radical nephrectomy in complex renal mass. Here, the authors reported the first case of this type to be managed via this surgical technique in Thailand. Case Report: A 76-year-old Thai female presented with right renal mass with tumor thrombus in the IVC extending 3 cm above the level of the renal vein. The presumed diagnosis was renal cell carcinoma of the right kidney with level 2 tumor thrombus in IVC, clinical staging T3bN0M0. The patient underwent robotic-assisted laparoscopic IVC thrombectomy together with right radical nephrectomy at Siriraj Hospital (Bangkok, Thailand) in May 2020. Results: The operation proceeded uneventfully without immediate complication. The postoperative reduction of IVC diameter was approximately 30%. Total IVC clamp time was 50 minutes, operative time was five hours, with docking time of 20 minutes and console time of 250 minutes, estimated intraoperative blood loss was 2,600 mL, and length of hospital stay was four days. At 30-days and 90-days postoperation, no thromboembolic event or compromising lower extremity venous return was detected. The pathological report revealed high-grade urothelial cell carcinoma with invasion into perinephric fat. Carcinoma involvement was observed in the tumor thrombus and IVC wall (T4N0M0). Conclusion: Robotic-assisted surgery of the IVC is a complex operation that requires robotic surgical proficiency and a highly experienced team. The observed success in the present case demonstrated the feasibly of this procedure in Thailand. Additional benefits include less postoperative pain, reduced blood loss, smaller surgical wound size, and shorter length of hospital stay. Keywords: Robotic-assisted laparoscopic radical nephrectomy; Inferior vena cava thrombectomy; Thailand

Sonographic evaluation of maternal blood loss after childbirth using postpartum inferior vena cava diameter among parturients in Kano Metropolis, Nigeria

Postpartum hemorrhage has been a major cause of maternal morbidity and mortality globally every year. Sonographic measurement of inferior vena cava diameter is a cheap, safe, non-invasive method and an indicator of blood loss after childbirth. The study was aimed to establish normal range values of postpartum inferior vena cava (IVC) among parturients in Kano metropolis, Nigeria. A prospective and longitudinal study from September, 2021 to September, 2022 was adopted and a minimum sample size of 210 measurements of IVC intraluminal diameter was calculated for the study using G Power sample size software. The sample comprised of two sets measurements obtained from 105 parturients before delivery and after delivery. The maternal heart rate and systolic blood pressure were measured. Blood samples from all subjects were collected. The data was analyzed using IBM Statistical Software. The range value of IVC diameter on inspiration of the subjects before childbirth was 13.2 mm – 20.3 mm, after childbirth was 9.1 mm – 16.7 mm. The IVC diameter range on expiration before childbirth was 17.3 mm – 24.8 mm, after childbirth was 12.6 mm – 21.4 mm. The Packed Cell Volume (PCV) range of the subjects before childbirth was 35% – 40%, after childbirth was 18% – 33%. The heart rate before childbirth was 64 bpm – 100 bpm, after childbirth was 70 bpm – 100 bpm. The systolic blood pressure before childbirth was 110 mmHg – 120 mmHg, after childbirth was 90 mmHg – 120 mmHg. The shock index before childbirth was 0.5 – 0.9 and after childbirth was 0.6 – 0.9. A statistical significant (p&lt;0.001) difference in IVC was observed. Furthermore, a statistical significant (p&lt;0.001) difference was obtained in PCV, maternal heart rate, systolic blood pressure and shock index. There was a statistical significant strong positive correlation between IVC and PCV during inspiration and expiration before and after childbirth.

Association of infraclavicular axillary vein diameter and collapsibility index with general anesthesia-induced hypotension in elderly patients undergoing gastrointestinal surgery: an observational study

BackgroundThe collapse index of inferior Vena Cava (IVC) and its diameter are important predictive tools for fluid responsiveness in patients, especially critically ones. The collapsibility of infraclavicular axillary vein (AXV) can be used as an alternative to the collapsibility of IVC (IVC-CI) to assess the patient’s blood volume.MethodsA total of 188 elderly patients aged between 65 and 85 years were recruited for gastrointestinal surgery under general anesthesia. Ultrasound measurements AXV and IVC were performed before induction of general anesthesia. Patients were grouped in accordance to the hypotension after induction. ROC curves were used to analyze the predictive value of ultrasound measurements of AXV and IVC for hypotension after induction of anesthesia. Pearson linear correlation was used to assess the correlation of ultrasound measurements and decrease in mean arterial blood pressure (MAP).ResultsThe maximum diameter of AXV(dAXVmax) and the maximum diameter of IVC (dIVCmax) were not related to the percentage decrease in MAP; the collapsibility of AXV (AXV-CI) and IVC-CI were positively correlated with MAP changes (correlation coefficients:0.475, 0.577, respectively, p < 0.001). The areas under the curve (AUC) was 0.824 (0.759–0.889) for AXV-CI, and 0.874 (0.820–0.928) for IVC-CI. The optimal threshold for AXV-CI was 31.25% (sensitivity 71.7%, specificity 90.1%), while for IVC-CI was 36.60% (sensitivity 85.9%, specificity 79.0%). Hypotension and down-regulation of MAP during induction can be accurately predicted by AXV-Cl after correction for confounding variables.ConclusionInfraclavicular axillary vein diameter has no significant correlation with postanesthesia hypotension, whereas AXV-CI may predict postanesthesia hypotension during gastrointestinal surgery of the elderly.Trial registrationThis study was registered in the Clinical Trial Registry of China on 05/06/2022 (ChiCTR2200060596).

Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion

Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and< 7mmHg. Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (β= 4.8; 95% CI, 2.6-7.1; P< .01) and 3 (β= 11; 95% CI, 8.9-14; P< .01) and RAP, VExUS grade of 2 (β= 6.8; 95% CI, 0.16-13; P= .045) and 3 (β= 15; 95% CI, 7.3-22; P< .01) and mean pulmonary artery pressure, and VExUS grade of 2 (β= 7.0; 95% CI, 3.9-10; P< .01) and 3 (β= 13; 95% CI, 9.5-17; P< .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10mmHg were 0.9 (95%CI, 0.83-0.97), 0.77 (95%CI, 0.68-0.88), and 0.65 (95%CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP< 7mmHg were 0.79 (95%CI, 0.70-0.87), 0.74 (95%CI, 0.64-0.84), and 0.62 (95%CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P= .025). Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.

Comparison of various surrogate markers for venous congestion in predicting acute kidney injury following cardiac surgery: A cohort study

BackgroundVenous congestion has been demonstrated to increase the risk of acute kidney injury (AKI) after cardiac surgery. Although many surrogate markers for venous congestion are currently used in clinical settings, there is no consensus on which marker is most effective in predicting AKI. MethodsWe evaluated various markers of venous congestion, including central venous pressure (CVP), inferior vena cava (IVC) diameter, portal pulsatility fraction (PPF), hepatic vein flow pattern (HVF), intra-renal venous flow pattern (IRVF), and venous excess ultrasound grading score (VExUS) in adult patients undergoing cardiac surgery to compare their ability in predicting AKI. ResultsAmong the 230 patients enrolled in our study, 53 (23.0%) developed AKI, and 11 (4.8%) required continuous renal replacement therapy (CRRT). Our multivariate logistic analysis revealed that IRVF, PPF, HVF, and CVP were significantly associated with AKI, with IRVF being the strongest predictor (odds ratio [OR] 2.27; 95% confidence interval [CI], 1.38–3.73). However, we did not observe any association between these markers and CRRT. ConclusionVenous congestion is associated with AKI after cardiac surgery, but not necessarily with CRRT. Among the markers tested, IRVF exhibits the strongest correlation with AKI.

Prognostic role of inferior vena collapsibility index in congenital heart disease: A validation study

BackgroundA recent study showed that inferior vena cava collapsibility index (IVCCI) <60% had better prognostic performance as compared to the American Society of Echocardiogram (ASE) criteria for estimating right atrial pressure (RAP). However, this study was based on a selected cohort of adults with congenital heart disease (CHD) that underwent right heart catheterization and limiting the generalizability of the results. The purpose of this study was, therefore, to validate the prognostic performance of IVCCI in a more representative sample of adults with CHD, which would in turn, improve generalizability of the results. MethodsRetrospective cohort study of adults with CHD that underwent echocardiogram at Mayo Clinic (2003−2021). Elevated RAP was defined as RAP >10 mmHg, and was estimated using IVCCI <60% or the ASE criteria (maximum IVC diameter < 2.1 cm and IVCCI <50%). Cardiovascular event was defined as heart failure hospitalization, heart transplant or cardiovascular death. ResultsOf the 4029 patients, 754 (19%) and 601 (15%) had elevated RAP (RAP >10 mmHg) based on IVCCI <60%, and the ASE criteria, respectively. Of the 4029 patients, 374 (9%) had cardiovascular events during 7.6 (4.4–10.5) years of follow-up. IVCCI <60% was independently associated with cardiovascular events (adjusted HR 2.08, 95% CI 1.75–2.42; C-statistic 0.708, 95%CI 0.688–0.728), and provided improved prognostic performance as compared to the ASE criteria (C-statistic difference 0.036, 95%CI 0.017–0.055, P = 0.008). ConclusionsIVCCI had superior prognostic performance as compared to the ASE criteria.

Phenotyping congestion in acute heart failure by renal flow and right heart to pulmonary circulation coupling.

In acute heart failure (AHF), kidney congestion is basic to treatment and prognosis. Its aetiology is manifold and quite unexplored in details mainly regarding the right heart to pulmonary circulation (Pc) coupling. We investigated the right heart to kidney interrelationship by Doppler renal flow pattern, right atrial dynamics, and right ventricular (RV) function to Pc coupling in AHF. In 119 AHF patients, echocardiographic and renal Doppler data were analysed. Univariate and multivariate regression models were performed to define the determinants of a quantitative parameter of renal congestion, the renal venous stasis index (RVSI). When grouped according to different intra-renal venous flow patterns, no differences were observed in haemodynamics and baseline renal function. Nonetheless, patients with renal Doppler evidence of congestion showed a reduced RV function [tricuspid annular plane systolic excursion (TAPSE), S'-wave velocity, and fractional area change], impaired RV to Pc coupling [TAPSE/pulmonary artery systolic pressure (PASP) ratio], and right atrial peak longitudinal strain (RAPLS), along with signs of volume overload [increased inferior vena cava (IVC) diameters and estimated right atrial pressure]. Univariate and multivariate regression analyses confirmed TAPSE/PASP, RAPLS, and IVC diameter as independent determinants of the RVSI. RVSI was the only variable predicting the composite outcome (cardiac death, heart failure hospitalization, and haemodialysis). An easy-to-use echo-derived right heart score of four variables provided good accuracy in identifying kidney congestion. In AHF, the renal venous flow pattern combined with a right heart study phenotypes congestion and clinical evolution. Keys to renal flow disruption are an impaired right atrial dynamics and RV-Pc uncoupling. Integration of four right heart echocardiographic variables may be an effective tool for scoring the renal congestive phenotype in AHF.