Point-of-care ultrasound to evaluate volume status in congestive heart failure

Figures

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  Fig. 1. Point-of-care ultrasound (POCUS) images of the inferior vena cava (IVC). A A typical POCUS image of the IVC depicting the liver, right atrium (RA), IVC, and cavoatrial junction (CAJ). The box indicates the optimal position for IVC assessment, 1–2 cm from the CAJ. B IVC POCUS suggesting the absence of volume overload with an IVC diameter ≤ 2.1 cm and an IVC collapsibility index (IVC-CI) > 50%. (C) IVC POCUS suggesting the presence of volume overload with IVC diameter > 2.1 cm and IVC-CI < 50%

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  Fig. 2. Point-of-care ultrasound (POCUS) of the internal jugular vein (IJV). A A typical POCUS image depicting the IJV, internal carotid artery (ICA), and IJV collapse point (arrow). B IJV POCUS suggesting the absence of volume overload with IJV collapsibility index (IJV-CI) ≥ 30%. C IJV POCUS suggesting the presence of volume overload with IJV-CI < 30%

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  Fig. 3. Focused cardiac ultrasound (FOCUS) findings which suggest congestive heart failure and volume overload. A Parasternal long-axis view demonstrating concentric left ventricular (LV) hypertrophy, which can be seen in heart failure with preserved ejection fraction. B A large pericardial effusion with evidence of right ventricular (RV) collapse, which may be seen in cardiac tamponade. Pericardial effusions can result from volume overload as well as numerous other etiologies. C Severe right atrial (RA) and RV enlargement, which can be seen in right-sided heart failure, typically resulting from pulmonary pathology. LA, left atrium

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  Fig. 4. Common lung point-of-care ultrasound (POCUS) findings. A Normal lung POCUS without evidence of pulmonary edema. Arrows with the letter A identify A-lines, or normal artifacts representing reverberation of the pleura. B Lung POCUS indicating greater than 3 B-lines (identified by arrows with the letter B), which is diagnostic of pulmonary edema

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  Fig. 5. Representative hepatic, portal, and intrarenal vein imaging sites and pulse-wave Doppler signals obtained when performing a Venous Excess Ultrasound Score (VExUS). A Hepatic vein Doppler waveforms demonstrating normal (systolic [S] wave greater than diastolic [D] wave), mildly abnormal (D wave greater than S wave), and severely abnormal (S wave reversal) patterns. B Portal vein Doppler waveforms demonstrating normal (< 30% pulsatility index), mildly abnormal (30%–49% pulsatility index), and severely abnormal (≥ 50% pulsatility index) patterns; pulsatility index = (maximum velocity – minimum velocity)/maximum velocity. C Intrarenal vein Doppler arterial (A) and venous (V) waveforms demonstrating normal (monophasic flow), mildly abnormal (discontinuous, biphasic flow with systolic [S] and diastolic [D] phases), and severely abnormal (discontinuous, monophasic flow with diastolic [D] phase only). Reused from Dinh [82], with permission from POCUS 101

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  Fig. 6. Proposed stepwise approach to point-of-care ultrasound (POCUS) for volume status assessment. Blue, red, yellow, and green boxes summarize POCUS studies that should be considered to evaluate the described clinical scenarios in outpatient, emergency department, inpatient ward, and intensive care settings, respectively. Black boxes and lines denote an approach to interpretation and further evaluation of the initial POCUS results. Proposed follow-up imaging intervals are listed in the blue, red, yellow, and green boxes on the right side of the diagram. This expert-opinion-based algorithm has not been prospectively validated; it should be used to supplement clinical judgement. *Supporting features for the presence of pulmonary hypertension include RV hypertrophy or dilation, RA dilation, and a D-shaped left ventricle. CHF, congestive heart failure; Dia, diastole; FOCUS, focused cardiac ultrasound; IJ, internal jugular; IJV, internal jugular vein; IJV-CI, internal jugular vein collapsibility index; IV, intravenous; IVC, inferior vena cava; IVC-CI, inferior vena cava collapsibility index; JVD, jugular venous distension; LV, left ventricle; LVEF, left ventricular ejection fraction; LVOT,…