Unloading Strategies in Advanced Heart Failure: The Role of Point–of–care Ultrasound

Abstract Patients with advanced heart failure (HF) exhibit repeated episodes of fluid retention (pulmonary and/or systemic congestion) and/or of reduced cardiac output at rest (peripheral hypoperfusion) requiring hospitalization along with diuretics/inotropic infusion. Pulmonary artery catheter (PAC) provides haemodynamic information to guide the therapy, however PAC is invasive and time consuming. Point of care ultrasonography (POCUS) represents a promising diagnostic tool at the bedside, performed by the physician to assess non invasively volume status, cardiac output and monitor decongestive therapy. Recently, abnormal Doppler flow patterns due to increased right atrial pressure have been described in the hepatic, portal, and intrarenal veins. Thus, the recent venous excess ultrasound score (VExUS) has been used to describe fluid status along with the diameter and collapsibility of the inferior vena cava. Furthermore HF patients show high filling pressures, therefore they often require mechanical or medical unloading. In this regard, point of care ultrasound represents a valid tool to monitor non invasively the filling pressures and the responsiveness to those treatments. Here, we illustrate with several clinical cases where VExUS/POCUS were pivotal in clinical management.