Portal Vein Doppler in Venous Congestion: Incremental Value, Dynamic Decongestion Monitoring, and Clinical Decision-Making in Heart Failure

Systemic venous congestion in heart failure (HF) is an active driver of organ dysfunction and adverse outcomes. Conventional assessment tools lack sensitivity for subclinical congestion and specificity for venous hypertension. Portal vein Doppler (PVD) is a point-of-care ultrasonography (POCUS) technique that directly evaluates splanchnic venous hemodynamics. This narrative review assesses whether PVD offers incremental value beyond standard congestion tools, inferior vena cava ultrasound, hepatic and intrarenal Doppler, and the VExUS score, while examining its role as a dynamic marker of decongestion and treatment response. PVD quantifies transmitted right-atrial pulsatility into the portal system. Current evidence supports its correlation with right-sided hemodynamics, prognostic value in HF (often within VExUS frameworks), and responsiveness to diuresis, ultrafiltration, and volume removal—particularly in severe tricuspid regurgitation and right-sided HF. However, PVD is affected by confounders including liver disease, mechanical ventilation, arrhythmias, intra-abdominal pressure, and technical errors. Its incremental value beyond other VExUS components remains unclear, and no trial has proven PVD-guided therapy improves outcomes. PVD is a feasible POCUS adjunct that refines congestion phenotyping and enables serial monitoring, especially when IVC assessment is equivocal or right-sided pathology dominates. It is not a standalone volume measure or validated therapeutic target. Future research requires standardized protocols, phenotype-specific validation, and interventional trials to determine whether PVD- or VExUS-guided strategies improve patient outcomes.