VExUS and right ventricular to pulmonary artery uncoupling

Figures

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  Fig. 1. Hemodynamic parameters and portal vein velocity (PVV) in a 79 year-old woman (A, B) before and (C, D) after mitral valve and aortic valve replacement and tricuspid annuloplasty. Note theworsening in pulmonary hypertension using the MAP/MPAP ration that went from 5 to 3.48 [12] and the reduction in the TAPSE/ systolic Ppa as coupling indice [13]. Both elements were associated with worsening of portal pulsatility. Post-operatively the patient was reexplored for tamponade, developed acute kidney injury and prolonged duration of stay in the ICU. Abbreviations: CPB, cardiopulmonary bypass; MAP. Mean arterial pressure; MPAP, mean pulmonary artery pressure; Pfa, femoral arterial pressure; Ppa, pulmonary artery pressure; Pra, radial artery pressure; Prv, right ventricular pressure, TAPSE, tricuspid annular plane systolic velocity; Vmin, minimal velocity; Vmax, maximal velocity

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  Fig. 2. Approach to the VExUS score. In the presence of abnormal VExUS score, history, labs, ECG and physical examination combined with POCUS or TEE as needed may provide the etiology. Abnormal VExUS score is the result of impaired coupling between RV contractility or ventricular elastance and pulmonary arterial afterload or arterial elastance. The two causes of an abnormal VExUS score is pulmonary hypertension (PHT) and RV failure or a combination of both. PHT can result from several mechanisms such as pre or post capillary for which the treatment will significantly differ. Similarly, RVF can result from ischemia which is worsened by RV dilatation. The role of the clinician is to identify the most likely mechanism(s) and identify the best personalized therapeutic approach which is not always fluid removal. Abbreviations: ECG, electrocardiogram; POCUS, point-of-care ultrasound; PA, pulmonary artery; PHT, pulmonary hypertension; RV, right ventricular; RVF, right ventricular failure; TEE, transesophageal echocardiography; VExUS, venous excess ultrasound score