Determinants and Prognostic Value of Persistent Congestion Assessed by Venous Excess Ultrasound Score in Acute Heart Failure

Background: Reliable quantification of systemic venous congestion in acute heart failure (HF) has become feasible with the advent of the venous excess ultrasound (VExUS) score, informing therapeutic management. Nevertheless, the determinants of the VExUS score trajectory during hospitalization and the prognostic implications of persistent subclinical congestion at discharge remain poorly defined. Methods: Consecutive patients admitted for acute HF were prospectively enrolled (n = 418, 73.3 ± 11.8 years old, 59.1% male). VExUS scores were assessed at admission and prior to discharge to categorize the patients into three groups: non-congested (persistent score of 0; n = 81), improved (score reduction of ≥1 point; n = 214), and non-improved (persistent congestion without score reduction; n = 123). Baseline clinical data were collected and all the patients had a transthoracic echocardiogram on admission. All patients were followed up post-discharge and the primary endpoint was a composite of all-cause mortality or HF hospitalization. Results: Patients with non-improved VExUS exhibited a higher burden of right-sided remodeling and dysfunction including larger right chambers, lower right ventricle (RV) systolic function indices, higher RV systolic pressures and a higher prevalence of severe tricuspid regurgitation (all p < 0.001). Severe tricuspid regurgitation was the sole independent predictor of VExUS non-improvement (OR 2.86, 95% CI 1.51–5.45, p = 0.001). Non-improved VExUS (HR 1.77; 95% CI 1.17–2.67; p = 0.007), severe tricuspid regurgitation (HR 1.88; 95% CI 1.16–3.02; p = 0.010) and intravenous furosemide dose (HR 1.00; 95% CI 1.00–1.01; p = 0.011) were independent predictors of the composite primary endpoint. Inclusion of non-improved VExUS provided incremental prognostic value over models including clinical, laboratory, and echocardiographic parameters (Δχ2= 9.22; p = 0.007). Conclusions: VExUS non-improvement throughout hospitalization marks patients with worse primary endpoint Severe tricuspid regurgitation emerges as an independent determinant of VExUS non-improvement which is independently associated with poor long-term outcomes.