Utilizing bedside VExUS and the S-prime velocity for real-time assessment of venous congestion on right ventricular function in heart failure

BACKGROUND: Right ventricular (RV) function is a major determinant of outcomes in heart failure (HF), yet RV systolic performance and venous congestion (VC) are often evaluated separately. We investigated the relationship between tricuspid annular systolic velocity (S'), a tissue Doppler marker of RV systolic function and systemic VC measured by the Venous Excess Ultrasound (VExUS) score in patients with HF. In addition, RV-pulmonary artery (RV-PA) coupling parameters including TAPSE/PASP and S'/PASP were evaluated across VExUS grades. METHODS: In this prospective, single-center observational study, 155 patients admitted with decompensated HF underwent standardized echocardiography, including VExUS assessment and S' measurement. Lung Ultrasound Score (LUS), RV-PA coupling indices, clinical characteristics, in-hospital mortality, and acute kidney injury (AKI) were also recorded. RESULTS: The mean age was 57.5 years, with 68% of the cohort being males. A significant inverse correlation was observed between VExUS grade and S' velocity (p < 0.001). Patients with VExUS Grade 0 had higher S' velocities (median = 11.0 cm/s), while those with Grade 3 had the lowest (8.5 cm/s). Increasing VExUS grades were also associated with progressive worsening of TAPSE, TAPSE/PASP, and S'/PASP ratios, suggesting impaired RV-PA coupling with increasing venous congestion. Both higher VExUS grades and reduced S' were associated with more severe pulmonary congestion on LUS (p < 0.001 and p = 0.003, respectively). Although patients with higher VExUS grades and lower S' values trended towards worse outcomes, neither parameter significantly predicted in-hospital mortality or AKI. CONCLUSION: Systemic VC and RV systolic function are strongly and inversely related in HF. The combined use of VExUS and S' provides an integrated bedside assessment of hemodynamic status that may help guide decongestive therapy. Integration of RV-PA coupling parameters may further enhance bedside evaluation of hemodynamic compromise in HF patients. Additionally, S'/PASP and TAPSE/PASP demonstrated comparable trends across all HF groups, suggesting that S'/PASP may serve as a practical alternative marker of RV-PA coupling in heart failure patients. Larger studies are needed to determine their prognostic utility for predicting mortality and organ injury. TRIAL REGISTRATION: This trial was registered with Clinical Trial Registry-India ( https://www.ctri.nic.in/ ), Trial Number - CTRI/2024/10/075219 on 14/10/2024.