Inferior Vena Cava Diameter Research Articles

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.
 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 < 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.
 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 <1.5 cm, while an IVC diameter of >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<0.001) difference in IVC was observed. Furthermore, a statistical significant (p<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.

The kinocardiograph for assessment of fluid status in patients with acute decompensated heart failure.

To improve telemonitoring strategies in heart failure patients, there is a need for novel non-obtrusive sensors that monitor parameters closely related to intracardiac filling pressures. This proof-of-concept study aims to evaluate the responsiveness of cardiac kinetic energy (KE) measured with the Kinocardiograph (KCG), consisting of a seismocardiographic (SCG) sensor and a ballistocardiographic (BCG) sensor, during treatment of patients with acute decompensated heart failure. Eleven patients with acute decompensated heart failure who were hospitalized for treatment with intravenous diuretics received daily KCG measurements. The KCG measurements were compared with the diameter of the inferior vena cava (IVC) and body weight. Follow-up stopped at discharge, that is, in the recompensated state. Median (interquartile range) weight and IVC diameter decreased significantly after diuretic treatment [weight 74.5 (67.6-98.7) to 73.3 (66.7-95.6) kg, P=0.003; IVC diameter 2.47 (2.33-2.99) to 1.78 (1.65-2.47) cm, P=0.03]. In contrast with BCG measurements, significant changes in median KE measured with SCG were observed during the passive filling phase of the diastole [SGG: 0.48 (0.39-0.60) to 0.69 (0.56-0.84), P=0.026; BCG: 0.68 (0.46-0.73) to 0.68 (0.59-0.82), P=0.062], the active filling phase of the diastole [SCG: 0.38 (0.30-0.61) to 0.31 (0.09-0.47), P=0.016; BCG: 0.29 (0.17-0.39) to 0.26 (0.20-0.34), P=0.248], and the ratio between the passive and active filling phases [SCG: 2.76 (1.68-5.30) to 5.02 (3.13-10.17), P=0.006; BCG: 5.87 (3.57-7.55) to 5.27 (3.95-9.43), P=0.790]. The correlations between changes in KE during the passive and active filling phases, using SCG, and changes in weight or IVC were non-significant. Systolic KE did not show significant changes. KE measured with the KCG using SCG is highly responsive to changes in fluid status. Future research is needed to confirm its accuracy in a larger study population and specifically its application for detection of clinical deterioration in the home-environment.

Processing Ultrasound Scans of the Inferior Vena Cava: Techniques and Applications.

The inferior vena cava (IVC) is the largest vein in the body. It returns deoxygenated blood to the heart from the tissues placed under the diaphragm. The size and dynamics of the IVC depend on the blood volume and right atrial pressure, which are important indicators of a patient's hydration and reflect possible pathological conditions. Ultrasound (US) assessment of the IVC is a promising technique for evaluating these conditions, because it is fast, non-invasive, inexpensive, and without side effects. However, the standard M-mode approach for measuring IVC diameter is prone to errors due to the vein movements during respiration. B-mode US produces two-dimensional images that better capture the IVC shape and size. In this review, we discuss the pros and cons of current IVC segmentation techniques for B-mode longitudinal and transverse views. We also explored several scenarios where automated IVC segmentation could improve medical diagnosis and prognosis.

Evaluation of an artificial intelligence-based system for echocardiographic estimation of right atrial pressure

Current noninvasive estimation of right atrial pressure (RAP) by inferior vena cava (IVC) measurement during echocardiography may have significant inter-rater variability due to different levels of observers’ experience. Therefore, there is a need to develop new approaches to decrease the variability of IVC analysis and RAP estimation. This study aims to develop a fully automated artificial intelligence (AI)-based system for automated IVC analysis and RAP estimation. We presented a multi-stage AI system to identify the IVC view, select good quality images, delineate the IVC region and quantify its thickness, enabling temporal tracking of its diameter and collapsibility changes. The automated system was trained and tested on expert manual IVC and RAP reference measurements obtained from 255 patients during routine clinical workflow. The performance was evaluated using Pearson correlation and Bland-Altman analysis for IVC values, as well as macro accuracy and chi-square test for RAP values. Our results show an excellent agreement (r=0.96) between automatically computed versus manually measured IVC values, and Bland-Altman analysis showed a small bias of -\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$-$$\\end{document}0.33 mm. Further, there is an excellent agreement ((p<0.01\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$(p<0.01$$\\end{document}) between automatically estimated versus manually derived RAP values with a macro accuracy of 0.85. The proposed AI-based system accurately quantified IVC diameter, collapsibility index, both are used for RAP estimation. This automated system could serve as a paradigm to perform IVC analysis in routine echocardiography and support various cardiac diagnostic applications.

Inferior vena cava diameter and risk of acute decompensated heart failure rehospitalisations

ObjectivesInferior vena cava (IVC) diameter may be a surrogate for volume status in acute decompensated heart failure (ADHF). The utility of IVC diameter measurement is under studied. The aim of...

The use of end-expiratory occlusion test vs. inferior vena cava respiratory variation for the prediction of volume responsiveness in mechanically ventilated patients with sepsis: A comparative study

ABSTRACT Sepsis being a chief prominent fatal condition in critically ill patients. In septic-shocked patients, the first-line therapeutic intervention is fluid resuscitation in an attempt to improve their cardiac output (COP). However, fluids must be given only if the chance of improving COP exists. So, assessing fluid responsiveness is crucial. To our knowledge, yet no studies comparing the end-expiratory occlusion (EEO) test and the variation of the inferior vena cava (IVC) diameter with respiration (ΔIVC) in hypovolemic cases. So, our aim is to use both tests as indices for responsiveness to fluid in septic mechanically ventilated (MV) patients. The Patients and Method: Thirty-four MV septic patients were enrolled and baseline COP assessment was performed followed by an EEO test applied to each patient, after which, COP was measured to detect the probable responders (defined as an increased COP by ≥ 15%) and non-responders. Then, ΔIVC was assessed for the same patients to predict the probable responders (with ΔIVC >12%) and non-responders. Finally, fluid therapy was initiated as per the guidelines of surviving sepsis campaign (2021) followed by COP re-assessment to determine actual fluid responders\ on-responders. Results: 67% of the cases was responding to fluid. Receiver operating characteristic showed areas under curve for EEO and ΔIVC in predicting responsiveness to fluid were 0.597 and 0.925, respectively. EEO (32.4%) was predictive with 47.8% sensitivity and 100% specificity. The ΔIVC (64.7%) was predictive with 91.3% sensitivity and 100% specificity. Conclusion: IVC-respiratory variation showed better values in prediction of response to fluid in MV patients with sepsis than EEO test.

Prognostic Value of Baseline Echocardiographic Parameters in Heart Failure With Improved vs Nonrecovered Ejection Fraction

BackgroundEjection fraction (EF) is often used as a prognostic indicator and for classifying heart failure (HF) patients. This study evaluates the association of echocardiographic parameters with HF with improved EF (HFimpEF). MethodsThis single-centre study retrospectively included patients with HF with reduced EF (HFrEF) from a cohort of admitted patients over 2018-2020, who were then followed up prospectively until 2023. The control group was categorized as patients with non-recovered HFrEF, and the population group was categorized as patients with HFimpEF. ResultsA total of 176 patients with HFrEF were included in the study. Non-ischemic etiology was found to be the most prevalent cause of HFimpEF. The baseline echocardiography examination revealed that the HFimpEF group exhibited significantly higher values for tricuspid annular plane systolic excursion (TAPSE; P < 0.001) and inferior vena cava diameter (P < 0.001). The non-recovered HFrEF group demonstrated higher baseline left atrial volume index (LAVi) values (P < 0.001). In multivariate analysis, a higher value of TAPSE (odds ratio 3.071; P = 0.008) and a lower value of LAVi (odds ratio 2.034; P = 0.008) were independent echocardiography variables associated with HFimpEF. After a mean follow-up duration of 32.5 ± 9.1 months, the HFimpEF group had higher survival from rehospitalization due to worsening HF and lower all-cause mortality (log rank P < 0.001 and P = 0.005, respectively). ConclusionsHigher TAPSE and lower LAVi in baseline were associated with the transition from HFrEF to HFimpEF. The HFimpEF group had better survival compared to those with non-recovered HFrEF.

Point-of-Care Ultrasonography for the Assessment of Dehydration in Children: A Systematic Review.

Accurate estimation of the degree of dehydration remains a diagnostic challenge. The primary objective was to systematically review the literature on the role of ultrasound in assessment of the degree of dehydration in children. Data sources included Ovid MEDLINE, Web of Science Core Collection, Current Index to Nursing and Allied Health Literature, Cochrane Library, ClinicalTrials.gov , and Trip Pro Database. Two independent reviewers used screening protocol to include articles on assessment of dehydration in children with the use of point-of-care ultrasonography (POCUS). The level of evidence was assessed in accordance with the "The Oxford 2011 Levels of Evidence." The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to evaluate risk of bias. We identified 108 studies, and 8 studies met our inclusion criteria. All studies were prospective cohort studies (level of evidence, 3-4). The authors of 5 studies used difference between ill weight and weight after rehydration as the reference standard for dehydration, and the authors of 3 studies used clinical dehydration scale. Two studies from the United States showed acceptable areas under the curve for inferior vena cava to aorta (IVC/Ao) diameter ratio at 0.72 and 0.73 for prediction of significant dehydration (>5% weight loss). The IVC/Ao ratio with cut-off at 0.8 had sensitivity of 67% and 86% and specificity of 71% and 56% for prediction of significant dehydration. Studies from the resource-limited settings were more heterogeneous. One study with acceptable risk of biases reported poor sensitivity (67%) and specificity (49%) of Ao/IVC ratio with cut-off of 2.0 for predicting severe dehydration (>9% weight loss) with area under the curve at 0.6. Three studies showed increase in IVC diameter with fluid resuscitation with mean change in IVC diameter by 30% in children with significant dehydration (>5% weight loss) and by 22% without significant dehydration (<5% weight loss). Metaanalysis was not completed due to high heterogeneity. This study showed that the quantity and quality of research on the application of POCUS for the assessment of dehydration in children is limited. There is no criterion standard for assessing the degree of dehydration and no universal definition of the degree of dehydration. Thus, more methodologically rigorous studies are required. Current systematic review does not support the routine use of US to determine the severity of dehydration in children. Despite these limitations, the use of POCUS in children with dehydration demonstrates potential. Given the clear increase in IVC size with rehydration, repeated IVC US scans may be helpful in guiding fluid resuscitation in children with dehydration. From different proposed US parameters, IVC/Ao ratio has better diagnostic accuracy in detecting significant dehydration than Ao/IVC ratio and IVC collapsibility index. Despite low to moderate diagnostic performance, US still showed better assessment of dehydration than physician gestalt and World Health Organization score.

Right Atrial Function Role in Tricuspid Regurgitation-Related Systemic Venous Congestion

Tricuspid regurgitation (TR) is a frequent valvular pathology and when significant, may cause systemic venous congestion (SC). The right atrium (RA) is an intermediate structure between the tricuspid valve and the venous system and its role in SC is not yet defined. A total of 116 patients with a measurable TR effective regurgitant orifice area (EROA) and regurgitant volume (RVol) were selected from 2020 to 2022. SC was estimated by echocardiography using inferior vena cava diameter and estimated right atrial pressure (eRAP) and by clinical congestive features. TR grade was mild in 23 patients (20%), moderate in 53 patients (46%), and severe in 40 patients (34%). There was a significant decrease in RA function measured by strain with increasing TR severity (p<0.001). There was a marked difference in RA strain between the groups with eRAP >10 and ≤10mmHg (25±11% vs 11±7%, p<0.0001). Variables independently associated with inferior vena cava diameter were RA strain (β -0.532, p<0.001), RA volume indexed (β 0.249, p=0.002), RVol (β 0.229, p=0.005) and EROA (β 0.185, p=0.016), and independently associated with eRAP >10mmHg were EROA (odds ratio [OR] 1.024, 95% confidence interval [CI] 1.002 to 1.046), RVol (OR 1.039, 95% CI 1.007 to 1.072) and RA strain (OR 0.863, 95% CI 0.794 to 0.940). The addition of RA strain to models containing EROA or RVol significantly improved the power of the model. RA strain was independently associated with the presence of 3 or more congestive features. In conclusion, echocardiographic and clinical signs of SC are frequent in higher degrees of TR, and RA function seems to play a key role in modulating the downstream effect of TR.

Echocardiographic parameters recommended for assessing the severity of tricuspid regurgitation: concordance and discordance.

Current guidelines recommend integrating several echocardiographic indices to evaluate the severity of tricuspid regurgitation (TR). Discordance of indices, including qualitative and quantitative methods, commonly exists in practice. The discordance among these parameters has not yet been fully elucidated. A total of 127 patients with recognizable TR jets without pulmonary regurgitation or intracardiac shunt were prospectively enrolled. We evaluated 8 parameters by 2-dimensional (2D) echocardiography: proximal iso-velocity surface area (PISA)-derived regurgitant volume (RVol), PISA-derived effective regurgitant orifice area (EROA), PISA radius, vena contracta width (VCW), color Doppler jet area, tricuspid valve annular diameter, inferior vena cava (IVC) diameter, and peak E wave. According to current guidelines, each echocardiographic parameter was determined to represent either severe or non-severe TR. A concordance score was calculated as the number of concordant parameters divided by 8, with a higher score reflecting better concordance. Data were further categorized into 3 subgroups: complete concordance (0 discordant parameters), high concordance (1-2 discordant parameters), and low concordance (3-4 discordant parameters). The mean concordance score was 81%±17% for the entire cohort. There were 48 (38%) patients with complete concordance, including 6 patients with severe TR. In contrast, the low concordance group (n=43, 34%) mostly comprised severe TR patients (36 patients). When considering only EROA, RVol, and VCW, concordance improved, with 98 patients (77%) in complete agreement. Concordance seems limited when using echocardiographic parameters to assess TR severity. Applying only EROA, RVol, and VCW results in better concordance, as recommended by the current guidelines.