Hepatic Vein Waveform Research Articles

Ultrasonographic Evaluation of Systemic Venous Congestion in Maintenance Hemodialysis Patients During Fluid Removal.

Fluid overload is a frequent and serious complication in hemodialysis patients. The combination of multiple point of care ultrasound (POCUS) measurements can identify significant venous congestion but its usefulness to determine ultrafiltration (UF) requirements and dry weight is unknown. Therefore, we evaluated prospectively patients in maintenance hemodialysis to establish the correlations between changes in venous congestion parameters and fluid removal. This was a prospective, single-center, observational study. POCUS venous congestion measurments were performed in 22 patients during 32 online post-dilutional hemodiafiltration sessions and findings were correlated with UF volume, central venous pressure and body water composition determined by multifrequency bioelectric impedance analysis (BIA). The pre dialysis weight was on average 1.9 kg above the BIA estimated dry weight, the average initial IVC diameter was <2 cm. An initial abnormal Hepatic Vein (HV) waveform was present in 26% (8) of the measurements. The average UF volume was 2084 ± 655 ml and correlated with changes in inferior vena cava (IVC) diameter (R= 0.34, CI 95% (0.18, 0.56) p < 0.05) but not with any other POCUS venous congestion parameters. Normalization of the IVC diameter and HV waveform was observed during the first UF hour in all initially altered measurements. Diameter reduction in the IVC correlated with total body water volume reduction estimated with BIA when measured immediately after fluid removal (R= 0.34, CI 95% (0.08, 0.56) p<0.05) Conclusion. Reduction in IVC diameter had a modest but significant correlation with UF volume in our patients on maintenance hemodiafiltration. POCUS may be used to monitor patients during UF.

A Prospective Study of Hepatic Vein Waveform, Damping Index, and Splenoportal Index in Liver Cirrhosis: Correlation with Child-Pugh Score

Background:Chronic liver disease evaluation is commonly conducted using the Child-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems. While the hepatic venous pressure gradient (HVPG) is the gold standard for measuring portal hypertension in cirrhotic patients, non-invasive alternatives such as Doppler ultrasonography offer a cost-effective, rapid, and less invasive option for assessment. Objective: This study aimed to investigate the correlation between hepatic vein waveform patterns, damping index, splenoportal index, and the Child-Pugh score in patients with liver cirrhosis to evaluate the efficacy of Doppler ultrasound as a non-invasive diagnostic tool. Methods: A prospective cross-sectional study was conducted at the Radiology Department of a public teaching hospital in Rawalpindi, Pakistan, from December 2023 to June 2024. A total of 52 patients with liver cirrhosis were included after excluding those with incomplete data or confounding conditions. Doppler ultrasound was used to assess hepatic vein waveform patterns, damping index, and splenoportal index. The Child-Pugh score was calculated based on clinical and laboratory parameters. Statistical analysis was performed using SPSS version 25, with a p-value of &lt;0.05 considered significant. The chi-square test, Fisher’s exact test, ANOVA, and ROC curve analyses were utilized for data evaluation. Results: The final cohort consisted of 52 patients, with 39 males (75%) and 13 females (25%). The mean age was 55.3 years. The damping index showed a significant increase from Child-Pugh Class A (0.45 ± 0.10) to Class C (0.75 ± 0.15) (p=0.003). The splenoportal index also demonstrated a significant rise from Class A (1.4 ± 0.3) to Class C (2.0 ± 0.5) (p=0.015). The sensitivity and specificity of the damping index (&gt; 0.6) in predicting higher Child-Pugh scores (B + C) were 52.6% and 85.7%, respectively, with a positive predictive value of 90.9%. Conclusion: The study found strong correlations between the severity of liver cirrhosis, as assessed by the Child-Pugh score, and Doppler ultrasound parameters such as hepatic vein waveforms and the damping index. Doppler ultrasound, therefore, presents itself as a precise, non-invasive alternative for evaluating the severity of liver disease, potentially replacing more invasive procedures.

Doppler ultrasound compared to shear wave elastography for assessment of liver cirrhosis

BackgroundThe progression of liver fibrosis to cirrhosis is a dynamic process necessitating non-invasive evaluation modalities. This study aims to evaluate the ability of Doppler ultrasound studies (DUS) in defining morphological and hemodynamic blood flow changes in the hepatic vasculature coinciding with advanced liver fibrosis.MethodsA prospective study was conducted on 100 patients with liver cirrhosis (F4). All cases underwent liver stiffness (LS) measurement by shear wave elastography (SWE), along with DUS to evaluate the liver texture, splenic size, hepatic artery resistive index (HARI), portal and splenic vein diameters, portal vein velocity (PVV), and hepatic vein waveform (HVV). All measures were assessed concurrently with a highly qualified single operator.ResultsPatients aged 55.5 ± 10.2 years with male predominance (72%). A highly significant correlation was found between LS by SWE and hepatic parenchymal texture, splenic size, portal vein width, and HVV (monophasic and biphasic) (p < 0.001). There were also high significant positive correlations (p < 0.001) between LS and PVV. However, there was no definitive correlation between LS and HARI, as well as splenic vein diameter.ConclusionThe widely available economic Doppler studies including portal vein velocity and hepatic vein waveform changes could be of substantial diagnostic value to liver cirrhosis.Study designProspective cohort study, employing descriptive and analytical statistics.

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 &amp;gt; 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 &amp;lt; 0.001), right ventricular fractional area change (R = -0.195, P &amp;lt; 0.001) and inferior vena cava diameter (R = 0.318, P &amp;lt; 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

Prediction of Esophageal Varices in Viral Hepatitis C Cirrhosis: Performance of Combined Ultrasonography and Clinical Predictors.

This study is aimed at evaluating the diagnostic performance of clinical predictors and the Doppler ultrasonography in predicting esophageal varices (EV) in patients with hepatitis C-related cirrhosis and exploring the practical predictors of EV. We conducted a prospective study from July 2020 to January 2021, enrolling 65 patients with mild hepatitis C-related cirrhosis. We obtained clinical data and performed grayscale and the Doppler ultrasound to explore the predictors of EV. Esophagogastroduodenoscopy (EGD) was performed as the reference test by the gastroenterologist within a week. The prevalence of EV in the study was 41.5%. Multivariable regression analysis revealed that gender (female, OR = 4.04, p = 0.02), platelet count (<150000 per ml, OR = 3.13, p = 0.09), splenic length (>11 cm, OR = 3.64, p = 0.02), and absent right hepatic vein (RHV) triphasicity (OR = 3.15, p = 0.03) were significant predictors of EV. However, the diagnostic accuracy indices for isolated predictors were not good (AUROC = 0.63-0.66). A combination of these four predictors increases the diagnostic accuracy in predicting the presence of EV (AUROC = 0.80, 95% CI 0.69-0.91). Furthermore, the Doppler assessment of the right hepatic vein waveform showed good reproducibility (κ = 0.76). Combining clinical and Doppler ultrasound features can be used as a screening test for predicting the presence of EV in patients with hepatitis C-related cirrhosis. The practical predictors identified in this study could serve as an alternative to invasive EGD in EV diagnosis. Further studies are needed to explore the diagnostic accuracy of additional noninvasive predictors, such as elastography, to improve EV screening.

Do Respiratory Maneuvers Affect Rght Hepatic Vein Waveform and Maximum Velocity in Post LDLT Recipients?

AIM: Â To evaluate the effect of respiratory maneuvers on right hepatic vein (RHV) Doppler waveform and its maximum velocity in Living donor liver transplant (LDLT) recipients. METHODS: This was a prospective cross-sectional study performed at Pakistan Kidney and Liver Institute and Research Centre (PKLI&amp; RC), Lahore Radiology department. The sample size of the study, calculated according to WHO sample size calculator, was 30 patients after applying the inclusion and exclusion criteria. Most of these patients were analyzed during their first post-operative week while staying in the surgical intensive care unit (SICU). The Doppler waveform and maximum velocity of RHV were recorded during normal gentle breathing, following breath-hold after deep inspiration and then after quiet expiration. The waveforms that were recorded were triphasic, biphasic, or monophasic in the pattern. To assess the RHV flow quantitatively, the Damping Index was also calculated during all these three respiratory maneuvers as follows (DI=Minimum velocity/maximum velocity) RESULTS: The maximum velocities during normal respiration, after quiet expiration and after breath-holding following deep inspiration were 125 cm/sec, 105 cm/sec and 94 cm/sec. The waveforms observed during gentle breathing were triphasic in 77%, biphasic in 10%, and monophasic in 13% of the patients. After quiet expiration, these were triphasic in 80%, biphasic in 6%, and monophasic in 13% of patients. However, after breath-hold following deep inspiration, the waveforms observed were triphasic in 42%, biphasic in 13%, and monophasic in 45% of the patients. (P &lt;0.008) CONCLUSION: The study showed that not only did the RHV waveforms show significant change from triphasic pattern to monophasic pattern, but also the peak velocities were lower following expiration. Therefore, during the Doppler ultrasound assessment of post-LDLT recipient patients, respiratory variations must be taken into consideration.

Hepatic Venous Stasis Index Reflects Hepatic Congestion and Predicts Adverse Outcomes in Patients With Heart Failure.

Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in patients with heart failure (HF). However, the parameter that quantifies hepatic vein waveforms has not been established. We suggest the hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in patients with HF, we aimed to clarify the associations of HVSI with the parameters of cardiac function and right heart catheterization, as well as that with prognosis, in patients with HF. Methods and Results We performed abdominal ultrasonography, echocardiography, and right heart catheterization in patients with HF (n=513). The patients were divided into 3 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). We examined the associations of HVSI with parameters of cardiac function and right heart catheterization and followed up for cardiac events defined as cardiac death or worsening HF. There was a significant increase in level of B-type natriuretic peptide, inferior vena cava diameter, and mean right atrial pressure with increasing HVSI. During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan-Meier analysis, cardiac event rate increased across increasing HVSI (log-rank, P=0.002). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF and is associated with adverse prognosis in patients with HF.

Utility of portal vein pulsatility fraction in patients undergoing corrective surgery for tetralogy of Fallot.

Right ventricle dysfunction is common after corrective surgery for tetralogy of Fallot and is associated with significant morbidity and mortality. We aimed to determine whether an increased portal vein pulsatility fraction (PVPF) was associated with worse clinical outcomes. In a prospective, observational, single-centre study, PVPF and other commonly used parameters of right ventricle function were assessed in patients of all ages undergoing corrective surgery for tetralogy of Fallot intraoperatively, with transesophageal echocardiography, before and after bypass, and post-operatively, with transthoracic echocardiography, at days 1, 2, at extubation, and at ICU discharge. The correlation was tested between PVPF and mechanical ventilation duration, prolonged ICU stay, mortality, and right ventricle function. The study included 52 patients, and mortality was in 3 patients. PVPF measurement was feasible in 96% of the examinations. PVPF in the immediate post-operative period had sensitivity of 73.3% and a specificity of 74.3% in predicting the occurrence of the composite outcome of prolonged mechanical ventilation, ICU stay, or mortality. There was a moderate negative correlation of PVPF with right ventricle fractional area change and right ventricle global longitudinal strain (r = -0.577, p < 0.001 and r = 0.465, p < 0.001, respectively) and a strong positive correlation with abnormal hepatic vein waveform (rho = 0.749, p < 0.001). PVPF is an easily obtainable bedside parameter to assess right ventricular dysfunction and predict prolonged mechanical ventilation, prolonged ICU stay, and mortality.

Noninvasive ultrasound technique for assessment of liver fibrosis and cardiac function in Fontan-associated liver disease: diagnosis based on elastography and hepatic vein waveform type

Noninvasive ultrasound technique for assessment of liver fibrosis and cardiac function in Fontan-associated liver disease: diagnosis based on elastography and hepatic vein waveform type

Impact of sustained virologic response in regression of portal hypertension in Egyptian patients with hepatitis C virus-associated cirrhosis and portal hypertension

BackgroundPortal hypertension (PH) is a common consequence in hepatitis C virus cirrhotic patients. With interferon alpha-based therapy, SVR was linked to improved PH and fibrosis regression. SVR to oral antiviral regimens is linked to reduced portal pressure in patients with clinically significant portal hypertension (CSPH) at baseline. However, CSPH continues in most of the patients. This study aims to assess the reversibility and/or improvement of PH in Egyptian patients with HCV-related cirrhosis and CSPH after achieving SVR with DAAs. The second aim is to evaluate performance of the noninvasive markers of fibrosis in prediction of the presence and/or reversibility of the CSPH in correlation to radiological and endoscopic parameters.Subjects and methodsWe evaluated noninvasive parameters, radiological and endoscopic signs of PH at baseline, and/or SVR 24 and SVR 48 post-DAA therapy in 40 patients with cirrhosis and CSPH (group A) and another 40 patients with cirrhosis only (group B).ResultsIn group A, the spleen diameter decreased from baseline (15.74 ± 1.53 cm), and SVR 24 (15.48 ± 1.51), to SVR 48 (15.35 ± 1.49 cm). No ascites detected at SVR 48 in 62.5%. Portal vein diameter and portal vein blood velocity reduced to 13.53 ± 1.07 mm and 14.14 ± 2.2 cm/s at SVR 48, with reversibility of hepatic vein waveform towards the triphasic pattern. Medium to large esophageal varices regressed from 52.5% to 2.5%, and up to 70% of patients showed no EVs at SVR 48. In group A, 24 patients showed complete reversibility of CSPH, and 16 patients showed improvement of CSPH. Child-Pugh score, FIB-4 index, King’s score, and Lok index revealed higher significance for detection of the presence of PH. Child-Pugh score, PC/SD ratio, and Lok index revealed higher significance for detection of reversibility of PH.ConclusionWe concluded that CSPH improved after SVR with DAAs and completely regressed in some patients. Upon predicting the presence of PH, Child-Pugh score, FIB-4 index, King’s score, and Lok index were the most significant noninvasive scores. While for predicting the reversibility of PH, Child-Pugh score, PC/SD ratio, and Lok index were the most significant scores.

Do Respiratory Maneuvers Affect The Hepatic Vein Waveforms And Maximum Velocity?

Aim: To assess the effect of respiratory maneuvers on hepatic vein waveforms and flow velocity in patients without liver or cardiac disease. Methods: This prospective cross-sectional study was conducted in the Radiology Department of Pakistan Kidney and Liver Institute and Research Center, Lahore (PKLI &amp; RC) after approval from Institutional Review Board (IRB). The sample size of 70 patients was selected using the WHO sample size calculator, after applying the inclusion and exclusion criteria. Doppler waveforms and maximum velocities (Vmax) of the middle hepatic vein were recorded during normal respiration, after quiet expiration, and following breath-hold after deep inspiration. The waveforms were classified as triphasic, biphasic, or monophasic. Results: The maximum velocities (Vmax) during normal respiration, after quiet expiration, and following deep inspiration were 26.67±9.41, 24.08±6.77 and 19.31±.61 respectively. During normal breathing, the middle hepatic vein waveforms were triphasic, biphasic and monophasic in 80%, 6%, and 14% of the patients respectively. After quiet expiration, these percentages were 82%, 4% &amp; 14% respectively and following breath-hold after deep inspiration, these percentages were 41%, 14% and 45%, respectively (p&lt;0.05). Conclusion: The hepatic venous velocities were lower after deep inspiration. Their waveforms showed significant change from triphasic pattern to monophasic pattern following deep inspiration. Therefore, the respiratory variations must be considered during hepatic vein Doppler ultrasound assessment. Keywords MeSH: Hepatic veins, velocities, waveforms, inspiration, expiration.

Hepatic Function Predictive Value of Hepatic Venous Waveform versus Portal Vein Velocity in Liver Cirrhosis.

Background:This study assessed the hepatic vein waveform (HVW) and mean maximum portal vein velocity (MM-PVV) on Doppler ultrasound in patients with liver cirrhosis (LC) and compared it with that of age and sex-matched controls. It correlated the degree of HVW abnormality and MM-PVV changes with liver function based on Child-Turcotte-Pugh (CTP) to determine which was more predictive of CTP.Methods:Sixty patients with LC and 60 healthy controls were consecutively recruited into this study. Each patient was classed based on the CTP system after relevant tests. Doppler evaluation of the hepatic vein (HV) and MM-PVV were performed. HVW obtained was classified either into triphasic, biphasic, or monophasic.Results:Sixty cirrhotic and 60 age-matched control subjects aged 19–69 and 18–69 years, respectively, completed this study. All control subjects had a normal HVW pattern while 46 (76.7%) cirrhotic subjects had abnormal HVW (P < 0.001). The MM-PVV was significantly lower in cirrhotic subjects than in controls; 22.8 cm/s versus 33.6 cm/s (P < 0.001). The degree of HVW abnormality among cirrhotics showed a significant positive correlation with CTP (r = 0.283, P = 0.029). MM-PVV on the other hand showed no correlation with CTP class (r = −0.124; P = 0.346). Linear regression showed that HVW was a significant predictor of hepatic dysfunction based on CTP.Conclusion:Changes in the waveform pattern of the HVs are a good predictor of the derangement of hepatic function in patients with LC than changes in PVV. HVW pattern could therefore serve as an adjunct to CTP class in hepatic function assessment.

Correlation between Hepatic Vein Wave form Changes on Doppler Ultrasound and the Severity of Diseases in Cirrhotic Patients

Background: Cirrhosis is a common problem and is a leading cause of chronic liver disease. Early diagnosis with assessment of severity of diseases may help prevent the associated complications and patients’ sufferings. Now a days Hepatic venous Doppler can be a tool for diagnosis of cirrhosis and to assess correlation between waveform changes and severity of diseases. Objective: The purposes of this study was to determine the significance of hepatic vein waveform changes on doppler ultrasound in cirrhotic patients and to correlate with liver dysfunction. Materials and methods: This study was carried out in the department of Radiology and Imaging of Enam Medical College and Hospital during January 2017 to May 2018. Doppler waveforms were obtained from right hepatic vein in all the cases and classified as triphasic, biphasic and monophasic. Waveform comparisons were made among patients with differing grades of cirrhosis. Child- Pugh class was used to assess severity of cirrhosis. Doppler sonography was done in 80 patients suspecting of having liver cirrhosis. Data on clinical findings, B mode sonographic findings and hepatic vein doppler ultrasound findings were collected and documented in structured forms. Analysis was done using SPSS - 20. Results: Total of 80 patients who met the inclusion criteria are included in the study with mean age of 45.37±7.64 (range 25-75) years. Among these 57 (71%) were males while 23(29%) were females. On the basis of hepatic function 25 (31%) patients presented in Child-Pugh Class A, 31(39%) with Class B and 24(30%) patients had Class C. Hepatic venous waveform was triphasic in 22 (27.5%), biphasic in 28(35%), and monophasic in 30 (37.5%) cases. Our study revealed 88% (21) of Child- Pugh Class C, 23% (7) of Class B and 8% (2) of class A patients had monophasic HV waveform. The hepatic venous waveform progressively changed from triphasic to biphasic to monophasic with advancing grade of cirrhosis. The relationship of these waveforms change had significant relation with hepatic dysfunction (p &lt; 0.022). Conclusion: Hepatic vein wave form changes reflects the change in hepatic circulation associated with progression of liver cirrhosis. It can be used as a new parameter in the assessment of severity of liver cirrhosis. Thus, alteration in hepatic venous blood flow pattern on doppler ultrasound can be a useful noninvasive tool for evaluating diseases severity in patients with cirrhosis. J MEDICINE 2021; 22: 100-106

Doppler ultrasonography is a useful tool for the diagnosis of hemodynamics in congestive graft injury due to heart failure after liver transplantation: A case report

IntroductionPatients with end-stage liver disease often have cardiac dysfunction, which can be worsened by hemodynamic instability in liver transplantation, causing congestive graft injury.Presentation of caseA 28-year-old male with Wilson's disease underwent liver transplantation. The patient's history included cirrhotic cardiomyopathy and a preoperative ejection fraction of 37% on echocardiography. After liver transplantation, massive transfusion and acute renal failure led to increased central venous pressure. Doppler ultrasonography (US) showed an increase in positive components of the hepatic vein triphasic wave, followed by pulsatile changes in the portal vein waveforms and an eventual to-and-fro pattern. Laboratory data showed severe elevations of hepatocellular transaminase levels. Based on Doppler US findings, we determined liver damage was due to passive congestion caused by heart failure. Immediate initiation of continuous hemodiafiltration (CHDF) and intra-aortic balloon pumping (IABP) led to the patient's recovery from severe heart failure and graft injury.DiscussionIn our case, changes in the hepatic and portal vein waveforms and marked elevation of hepatocellular transaminases implied exacerbation of heart failure caused by hepatic congestion and injury. Worsening heart failure, in turn, led to progressive liver damage as the result of hepatic passive congestion. The patient's condition was successfully managed with early initiation of CHDF and IABP.ConclusionDoppler US can help diagnose congestive graft injury due to heart failure in liver transplant patients and should be performed during post-transplant management of patients with cardiac dysfunction.

Role of hepatic Doppler as compared to Fibro-scan in evaluation of post virus C hepatic fibrosis

Abstract Background Chronic infection with hepatitis C virus (HCV) is a disease of global importance with a large burden of morbidity and mortality. hepatitis c virus can cause progressive liver damage which may result in liver cirrhosis and hepato-cellular carcinoma . Aim of the work The aim of our study was to examine the efficacy of hepatic Doppler indices, namely hepatic vein wave form, hepatic vein maximum velocity ,hepatic artery RI and portal vein maximum velocity and portal vein wave form for evaluating the degree of hepatic fibrosis in chronic hepatitis C (CHC) patients as compared to transient elastography. Patients and methods our study was done over period from September 2018 till April 2019 included 40 patients from eldemerdash hospital designed to include all hepatitis c positive patients with any age or sex excluding other cause of liver cirrhosis (negative hepatitis B, negative auto immune hepatitis) in absence of obesity or ascites. hepatic vein maximum velocity, hepatic artery RI, portal vein maximum velocity, TE were performed to all patients. fibrosis was assessed on semi quantitative scoring system (METAVIR score ). we examine the efficacy of each of Doppler indices in differentiating different stages of hepatic fibrosis and their diagnostic accuracy in predicting significant fibrosis and cirrhosis . Results on comparing the fibrosis &amp;non fibrosis groups by TE according to Doppler measurement we found statistically significant higher means of the portal vein maximum velocity (PVmax) for the non fibrosis group as compared to the fibrosis group (24.15±9.71 and 15.94±3.35 respectively with p value&amp;lt;0.001) also found significantly lower HAPSV/PVmax ratio for the non fibrosis as compared to fibrosis group (1.58±0.41 and 2.59±1.17 respectively with p value 0.011) finally, we found that there was significant change of the HV waveform pattern for the non fibrosis (normal triphasic ) as compared to fibrosis (monophasic or biphasic ) (x2=4.353 with p value 0.038)

Liver Congestion Assessed by Hepatic Vein Waveforms in Patients With Heart Failure

BackgroundIt has been reported that the pattern of hepatic vein (HV) waveforms determined by abdominal ultrasonography is useful for the diagnosis of hepatic fibrosis in patients with chronic liver disease. We aim to clarify the clinical implications of HV waveform patterns in patients with heart failure (HF). MethodsWe measured HV waveforms in 350 HF patients, who were then classified into 3 categories based on their waveforms: those with a continuous pattern (C group); those whose V wave ran under the baseline (U group), and those with a reversed V wave (R group). We performed right-heart catheterization, and examined the rate of postdischarge cardiac events, such as cardiac death and rehospitalization due to worsening HF. ResultsThe number of patients in each of the 3 HV waveform groups was as follows: C group, n = 158; U group, n = 152, and R group, n = 40. The levels of B-type natriuretic peptide (R vs C and U; 245.8 vs 111.7 and 216.6 pg/mL; P < 0.01) and mean right atrial pressure (10.5 vs 6.7 and 7.2 mm Hg; P < 0.01) were highest in the R group compared with the other groups. The Kaplan-Meier analysis found that cardiac event–free rates were lowest in the R group among all groups (log-rank P < 0.001). In the multivariable Cox proportional hazard analysis, the R group was found to be an independent predictor of cardiac events (hazard ratio, 4.90; 95% confidence interval, 2.23-10.74; P < 0.01). ConclusionAmong HF patients, those with reversed V waves had higher right atrial pressure and were at higher risk of adverse prognosis.

Noninvasive ultrasound technique for assessment of liver fibrosis and cardiac function in Fontan-associated liver disease: diagnosis based on elastography and hepatic vein waveform type.

Patients with a Fontan circulation tend to develop liver fibrosis, liver cirrhosis and even hepatocellular carcinoma. A noninvasive ultrasound technique for liver fibrosis and cardiac function assessment in Fontan-associated liver disease (FALD) is needed to evaluate disease progression in real time. This study aimed to evaluate whether hepatic vein (HV) waveform analysis and elastography could be alternative markers to cardiac index (CI) in patients with FALD and assess factors influencing elastography measurements in FALD cases. All patients underwent cardiac catheterization, B-mode ultrasound and ultrasound elastography measurement. Moreover, we measured serum markers related to fibrosis and examined HV blood flow using duplex Doppler ultrasonography. Forty-three patients (median age, 17years; interquartile range, 12-25years; 29 men, 6 with liver biopsy) were enrolled. The real-time tissue elastography (RTE) value was significantly higher in patients who underwent surgery > 7years prior, suggesting that this value probably reflects the liver fibrosis due to FALD from the early fibrosis stage. The ultrasound elastography did not significantly correlate with hemodynamic parameters. The area under the receiver operating curve for the diagnosis of CI < 2.2 L/min/m2 using HV waveform was superior to the results from elastography and calculated fibrosis indices. HV waveform can be used as a noninvasive measurable surrogate marker for CI. The RTE value increased overtime after the operation and would reflect liver fibrosis. The combination of RTE and HV waveform type could be useful noninvasive tools to evaluate clinical conditions in FALD patients in real time.

Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study.

BackgroundFluid overload is deleterious in critically ill patients. It can lead to venous congestion, thereby increasing venous pressure, theoretically increasing the backpressure, and thereby reducing renal blood flow. Venous congestion thus can be an important contributor to acute kidney injury (AKI), with no validated tools to objectively identify venous congestion bedside.Materials and methodsPatients above 18 years admitted in ICU with a provisional diagnosis of cardiorenal syndrome were included in the study. Those with inadequate window, inferior vena cava (IVC) thrombus, and known case of cirrhosis with portal hypertension were excluded from the study. Patients underwent ultrasound examination with serial determination till AKI resolved or patient is initiated on dialysis. Venous excess ultrasound score (VEXUS) comprising inferior vena cava, hepatic vein waveform, and portal vein pulsatility was assessed.ResultsThirty patients were enrolled for the study. The mean age was 59.53 ± 16.47 with 21 (70%) males. Mean sequential organ failure assessment (SOFA) score was 5.03 ± 1.97. Fourteen patients (46.7%) were in AKI stage 1, while eight patients (26.7%) were in AKI stage 2 and stage 3 each. Twenty patients (66.7%) had VEXUS grade III. Resolution of AKI injury showed significant correlation with improvement in VEXUS grade (p value 0.003). Similarly, there was significant association between changes in VEXUS grade and fluid balance (p value 0.006). There was no correlation between central venous pressure (CVP), left ventricular function, and right ventricular function with change in VEXUS grade.ConclusionThe study shows that a combined grading of IVC, hepatic vein, and portal vein might reliably demonstrate venous congestion and aid in the clinical decision to perform fluid removal.How to cite this articleBhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, et al. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(9):783–789.

Role of hepatic colour duplex ultrasound in assessment of non alcoholic fatty liver disease-nafld

Abstract Background Gray-scale ultrasonography (US) is an initial, easy to use and widely available imaging modality for NAFLD, the presence of fat infiltration in the liver in the absence of excessive alcohol consumption and other causes of liver disease, is the most common cause of fatty liver, with a prevalence as high as 15-25% in many populations. Objective to determine the effect of obesity and NAFLD on the Doppler waveform pattern of the liver vascularity. Methods A case control study, conducted at Ain Shams University in the period between july and December 2018 . In both groups, liver span &amp; subcutaneous fat was measured by ultrasonographic examination. Hepatic vein waveform pattern &amp; portal vein mean flow velocity were assessed &amp; hepatic artery resistance index was measured by duplex Doppler ultrasonography examination. Results Our study included 50 patients , 20 were control &amp; 30 were cases.. The mean age of cases was 45.30 ± 10.15 SD &amp; the mean age of control was 32.70 ± 10.95 SD rendering the mean age of cases &amp; control of high statistical significance (p value=0.000). The Subcutaneous fat showed high significant statistical difference between cases &amp; control groups with mean subcutaneous fat in control =0.75 ± 0.14 SD &amp; mean subcutaneous fat in cases= 1.23 ± 0.42 SD with p –value = 0.000. The liver span showed high significant statistical difference between cases &amp; control groups with mean in control =15.11 ± 0.85 SD &amp; mean liver span in cases= 17.46 ± 1.67SD ( p value = 0.000). Hepatic vein wave pattern was normal in all 20 control (100%). In the 30 cases,the Hepatic vein wave pattern was triphasic in 12 patients (40%) &amp; biphasic or monophasic In 18 patients (60%) with high statistical significance (p-value =0.000). There was negative correlation between the hepatic vein velocity &amp; BMI with ( p value=0.0032). There was no statistically significant difference between cases &amp; control as regards all Doppler indices including the Hepatic artery RI(resistive index), Hepatic artery PSV(peak systolic velocity), Portal vein velocity(maximum &amp; minimum)&amp; hepatic vein velocity (maximum velocity) where the p value was more than 0.05. Conclusion Patients with NAFLD have a high rate of abnormal hepatic vein Doppler waveform patterns ,which can be biphasic or monophasic rather than alterations in hepatic artery resistance index values by duplex Doppler ultrasonography. Also the fatty infiltration of hepatocytes can increase liver span &amp; the subcutaneous fat.

Role of Colour Doppler Ultrasound in the Diagnosis and Grading of Liver Cirrhosis Compared with Transient Elastograpgy (Fibroscan)

The purpose of this study was to determine the morphological changes in hepatic vasculature and the flow hemodynamics in portal vein, hepatic veins and hepatic artery using various Doppler parameters in cirrhotic patients and to evaluate the variation in Doppler flow hemodynamics within cirrhotic livers as compared to liver stiffness measured by transient elastography. Study sample of 100 eligible patients with compensated liver cirrhosis were enrolled. All were examined with a pulsed Doppler flowmeter with a 3.75 MHz convex and sector probe. Liver texture, splenic size, portal and splenic vein diameters, portal vein velocity, hepatic artery resistive index and waveform of the hepatic vein were evaluated in all subjects comparing results with liver stiffness measured by transient elastography. All the data were collected, tabulated and statistically analyzed using an IBM personal computer with Statistical Package of Social Science version 22. The mean age of the patients was found to be 51.8 ± 10.2 years. The mean value of liver stiffness was 39.7 ± 18.0 kPa. The echotexture of liver was coarse with irregular margin in 69 patients (69.0%), coarse with smooth margin in 24 patients (24.0 %) and normal in 7 patients (7.0 %). The size of spleen was enlarged in 92.0 % of patients. Portal vein diameter was enlarged in 66.0 % of patients. Portal vein velocity shows abnormality in 65.0 % of patients. Hepatic vein waveform in 7.0% of patients was triphasic and non-triphasic in 93.0%. Hepatic artery restrictive index increased above normal range in 69.0 % of patients. Splenic vein diameter was enlarged in 92.0 %. There were statistically highly significant relations (P value < 0.001) between liver stiffness measured by transient elastography and liver texture, hepatic vein waves in colour Doppler US. A highly significant negative correlation (P value < 0.001) was found between Fibroscan results and portal vein velocity in our included cirrhotic patients. Fibroscan results had highly significant positive correlations (P value < 0.001) with splenic size, portal vein diameter, HARI and splenic vein diameter. Colour Doppler US play an important role in the diagnosis of the morphological changes in hepatic vasculature and the flow hemodynamics in portal vein, hepatic veins and hepatic artery. Fibroscan could predict changes in intrahepatic vascular resistance and it improves the accuracy of Doppler US in the detection of cirrhosis.