Portal vein doppler improvement predicts lower in-hospital mortality in acute decompensated heart failure with right ventricular dysfunction: a prospective cohort study

Background Venous Excess Ultrasound (VExUS) is increasingly used for risk stratification and monitoring decongestion in acute decompensated heart failure (ADHF). Yet, its clinical validity in the setting of right ventricular (RV) dysfunction remains uncertain, where elevated right-sided pressures and compliance may modify Doppler signals. Among VExUS components, portal vein Doppler may be less directly influenced by right atrial pressure fluctuations than hepatic vein Doppler, potentially providing a pragmatic target for serial assessment of venous congestion in RV dysfunction. Purpose To assess whether improvement in portal venous Doppler is associated with in-hospital mortality among ADHF patients with RV dysfunction. Methods A prospective cohort of adults (> 18 years) admitted to a cardiac intensive care unit with ADHF and RV dysfunction was evaluated. Venous congestion assessment was performed on day 1 and day 3, including portal vein Doppler grading and other VExUS components. The exposure was an improvement of at least 1 portal vein Doppler grade between assessments. The primary outcome was in-hospital mortality. Associations were tested using logistic regression. Discrimination was assessed using the area under the receiver operating characteristic (ROC) curve (AUC) with 95% confidence intervals and AUCs were compared using DeLong’s test. Results Among 68 patients with RV dysfunction (median age 61 years; 74% male; median left ventricular ejection fraction 20%; median TAPSE 13 mm), baseline characteristics were broadly balanced between groups. In complete-case analyses (n=63), in-hospital mortality was 12/63 (19%). Portal vein Doppler improvement occurred in 32/63 (51%) and was associated with lower mortality (1/32, 3.1%) compared with no improvement (11/31, 35.5%). Logistic regression showed portal improvement was associated with lower in-hospital mortality (odds ratio 0.06, 95% confidence interval 0.003 to 0.34; p=0.009). Discrimination for in-hospital mortality was higher for portal improvement (AUC 0.76, 95% CI 0.65 to 0.85) than for hepatic vein improvement (AUC 0.64, 95% CI 0.53 to 0.74; DeLong p=0.002), and similar to composite VExUS improvement (AUC 0.72, 95% CI 0.60 to 0.81; DeLong p=0.25). Among patients with moderate-to-severe tricuspid regurgitation, no in-hospital deaths occurred in those with portal improvement (0/22, 0%) versus 7 deaths among 19 patients without portal improvement (7/19, 36.8%), suggesting that portal improvement may identify a low-risk subgroup; however, interaction testing was not statistically significant. Conclusion(s) In ADHF patients with RV dysfunction, early isolated improvement in portal vein Doppler grade was strongly associated with lower in-hospital mortality and showed discriminative performance comparable to VExUS improvement. Serial portal vein Doppler assessment may provide a pragmatic marker of decongestion response in this high-risk population.