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Murayama M, Kaga S, Onoda A, Nishino H, Yokoyama S, Goto M, Suzuki Y, Yanagi Y, Shimono Y, Nakamura K, Aoyagi H, Tamaki Y, Ishizaka S, Iwano H, Kamiya K, Nagai T, Anzai T. Head-to-Head Comparison of Hepatic Vein and Superior Vena Cava Flow Velocity Waveform Analyses for Predicting Elevated Right Atrial Pressure. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1352-1360. [PMID: 38834491 DOI: 10.1016/j.ultrasmedbio.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 04/27/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVE Blood flow in the hepatic veins and superior vena cava (SVC) reflects right heart filling; however, their Doppler profiles are often not identical, and no studies have compared their diagnostic efficacies. We aimed to determine which venous Doppler profile is reliable for detecting elevated right atrial pressure (RAP). METHODS In 193 patients with cardiovascular diseases who underwent cardiac catheterization within 2 d of echocardiography, the hepatic vein systolic filling fraction (HV-SFF) and the ratio of the peak systolic to diastolic forward velocities of the SVC (SVC-S/D) were measured. HV-SFF < 55% and SVC-S/D < 1.9 were regarded as elevated RAP. We also calculated the fibrosis 4 index (FIB-4) as a serum liver fibrosis marker. RESULTS HV-SFF and SVC-S/D were feasible in 177 (92%) and 173 (90%) patients, respectively. In the 161 patients in whom both venous Doppler waveforms could be measured, HV-SFF and SVC-S/D were inversely correlated with RAP (r = -0.350, p < 0.001; r = -0.430, p < 0.001, respectively). SVC-S/D > 1.9 showed a significantly higher diagnostic accuracy of RAP elevation compared with HV-SFF < 55% (area under the curve, 0.842 vs. 0.614, p < 0.001). Multivariate analyses showed that both FIB-4 (β = -0.211, p = 0.013) and mean RAP (β = -0.319, p < 0.001) were independent determinants of HV-SFF. In contrast, not FIB-4 but mean RAP (β = -0.471, p < 0.001) was an independent determinant of SVC-S/D. The diagnostic accuracy remained unchanged when HV-SFF < 55% was considered in conjunction with the estimated RAP based on the inferior vena cava morphology. Conversely, SVC-S/D showed an incremental diagnostic value over the estimated RAP. CONCLUSIONS SVC-S/D enabled a more accurate diagnosis of RAP elevation than HV-SFF.
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Affiliation(s)
- Michito Murayama
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan; Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Sanae Kaga
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan; Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.
| | - Airi Onoda
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hisao Nishino
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Shinobu Yokoyama
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Mana Goto
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yukino Suzuki
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yusuke Yanagi
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yui Shimono
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kosuke Nakamura
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yoji Tamaki
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hiroyuki Iwano
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Hokkaido, Japan; Division Cardiology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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Beaubien-Souligny W, Galarza L, Buchannan B, Lau VI, Adhikari NK, Deschamps J, Charbonney E, Denault A, Wald R. Prospective Study of Ultrasound Markers of Organ Congestion in Critically Ill Patients With Acute Kidney Injury. Kidney Int Rep 2024; 9:694-702. [PMID: 38481488 PMCID: PMC10927464 DOI: 10.1016/j.ekir.2023.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 06/03/2024] Open
Abstract
INTRODUCTION Organ congestion may be a mediator of adverse outcomes in critically ill patients with severe acute kidney injury (AKI). The presence of abnormal venous Doppler waveforms could identify patients with clinically significant organ congestion who may benefit from a decongestive strategy. METHODS This prospective multicenter cohort study enrolled patients with severe AKI defined as Kidney Disease: Improving Global Outcomes stage 2 or higher. Patients were not eligible if they received renal replacement therapy (RRT) for more than 72 hours at the time of screening. Participants underwent serial Doppler ultrasound examinations of the portal, hepatic and intrarenal veins during the week following enrolment. We calculated the venous excess ultrasound (VExUS) score based on these data. The primary outcome studied was major adverse kidney events at 30 days (MAKE30) defined as death, RRT dependence, or a persistent decrease in kidney function. RESULTS A total of 125 patients were included for whom 291 ultrasound assessments were performed. Severely abnormal venous waveforms were documented in 14.4% of portal vein assessments, 6.5% of intrarenal venous assessments, and 14.4% of hepatic vein assessments. The individual ultrasound markers were not associated with MAKE30. The VExUS score (grade 0-1: reference; grade 2: adjusted hazard ratio [aHR]: 4.03, confidence interval [CI]: 1.81-8.99; grade 3: aHR: 2.70, CI: 1.10-6.65; P = 0.03), as well as severely abnormal portal, hepatic and intrarenal vein Doppler were each independently associated with mortality. CONCLUSION Although not significantly associated with MAKE30, venous Doppler abnormalities suggestive of venous congestion were associated with higher mortality in critically ill patients with severe AKI.
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Affiliation(s)
- William Beaubien-Souligny
- Innovation hub, Centre de recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
- Division of Nephrology, Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitari de Castelló, Castelló de la Plana, Spain
| | - Brian Buchannan
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vincent I. Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton, Alberta, Canada
| | - Neill K.J. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jean Deschamps
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emmanuel Charbonney
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - André Denault
- Division of Anesthesiology, Montreal Heart Institute, Montréal, Quebec, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
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Hobbs H, Millington S, Wiskar K. Multiorgan Point-of-Care Ultrasound Assessment in Critically Ill Adults. J Intensive Care Med 2024; 39:187-195. [PMID: 37552930 PMCID: PMC10845831 DOI: 10.1177/08850666231192047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/14/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023]
Abstract
Traditional point-of-care ultrasound (POCUS) training highlights discrete techniques, single-organ assessment, and focused protocols. More recent developments argue for a whole-body approach, where the experienced clinician-ultrasonographer crafts a personalized POCUS protocol depending on specific clinical circumstances. This article describes this problem-based approach, focusing on common acute care scenarios while highlighting practical considerations and performance characteristics.
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Affiliation(s)
- Hailey Hobbs
- Department of Critical Care Medicine, Queen's University, Kingston, Canada
| | - Scott Millington
- Critical Care Medicine, The University of Ottawa/The Ottawa Hospital, Ottawa, Canada
| | - Katie Wiskar
- Clinical Instructor, Division of General Internal Medicine, University of British Columbia, Vancouver, Canada
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Dimitriadis K, Damianaki A, Bletsa E, Pyrpyris N, Tsioufis P, Theofilis P, Beneki E, Tatakis F, Kasiakogias A, Oikonomou E, Petras D, Siasos G, Aggeli K, Tsioufis K. Renal Congestion in Heart Failure: Insights in Novel Diagnostic Modalities. Cardiol Rev 2024:00045415-990000000-00224. [PMID: 38427026 DOI: 10.1097/crd.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Heart failure is increasingly prevalent and is estimated to increase its burden in the following years. A well-reported comorbidity of heart failure is renal dysfunction, where predominantly changes in the patient's volume status, tubular necrosis or other mechanical and neurohormonal mechanisms seem to drive this impairment. Currently, there are established biomarkers evaluating the patient's clinical status solely regarding the cardiovascular or renal system. However, as the coexistence of heart and renal failure is common and related to increased mortality and hospitalization for heart failure, it is of major importance to establish novel diagnostic techniques, which could identify patients with or at risk for cardiorenal syndrome and assist in selecting the appropriate management for these patients. Such techniques include biomarkers and imaging. In regards to biomarkers, several peptides and miRNAs indicative of renal or tubular dysfunction seem to properly identify patients with cardiorenal syndrome early on in the course of the disease, while changes in their serum levels can also be helpful in identifying response to diuretic treatment. Current and novel imaging techniques can also identify heart failure patients with early renal insufficiency and assess the volume status and the effect of treatment of each patient. Furthermore, by assessing the renal morphology, these techniques could also help identify those at risk of kidney impairment. This review aims to present all relevant clinical and trial data available in order to provide an up-to-date summary of the modalities available to properly assess cardiorenal syndrome.
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Affiliation(s)
- Kyriakos Dimitriadis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | | | - Evanthia Bletsa
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Nikolaos Pyrpyris
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Theofilis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Fotis Tatakis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Alexandros Kasiakogias
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | | | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Konstantina Aggeli
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Di Maria A, Siligato R, Bondanelli M, Fabbian F. Venous Doppler flow patterns, venous congestion, heart disease and renal dysfunction: A complex liaison. World J Cardiol 2024; 16:5-9. [PMID: 38313388 PMCID: PMC10835472 DOI: 10.4330/wjc.v16.i1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024] Open
Abstract
The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on. We focused our attention on venous congestion. In intensive care settings, it is now widely accepted that venous congestion is an important clinical feature worthy of investigation. Evaluating venous Doppler profile abnormalities at multiple sites could suggest adequate treatment and monitor its efficacy. Renal dysfunction could trigger or worsen fluid overload in heart disease, and cardio-renal syndrome is a well-characterized spectrum of disorders describing the complex interactions between heart and kidney diseases. Fluid overload and venous congestion, including renal venous hypertension, are major determinants of acute and chronic renal dysfunction arising in heart disease. Organ congestion from venous hypertension could be involved in the development of organ injury in several clinical situations, such as critical diseases, congestive heart failure, and chronic kidney disease. Ultrasonography and abnormal Doppler flow patterns diagnose clinically significant systemic venous congestion. Cardiologists and nephrologists might use this valuable, non-invasive, bedside diagnostic tool to establish fluid status and guide clinical choices.
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Affiliation(s)
- Alessio Di Maria
- Specialized Medicines, Renal Unit, University Hospital St. Anna of Ferrara, Ferrara I-44124, Italy
| | - Rossella Siligato
- Specialized Medicines, Renal Unit, University Hospital St. Anna of Ferrara, Ferrara I-44124, Italy
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina I-98121, Italy
| | - Marta Bondanelli
- Department of Medical Sciences, University of Ferrara, Ferrara I-44124, Italy
| | - Fabio Fabbian
- Department of Medical Sciences, University of Ferrara, Ferrara 44124, Italy.
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Galarza Barrachina L, Colinas Fernández L, Martín Bermúdez R, Fernández Galilea A, Martín-Villén L. Abdominal ultrasound and VExUS score in critical care. Med Intensiva 2023; 47:658-667. [PMID: 38783747 DOI: 10.1016/j.medine.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/23/2023] [Indexed: 05/25/2024]
Abstract
The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.
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Affiliation(s)
| | | | | | | | - Luis Martín-Villén
- UGC Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Andrei S, Bahr PA, Nguyen M, Bouhemad B, Guinot PG. Prevalence of systemic venous congestion assessed by Venous Excess Ultrasound Grading System (VExUS) and association with acute kidney injury in a general ICU cohort: a prospective multicentric study. Crit Care 2023; 27:224. [PMID: 37291662 DOI: 10.1186/s13054-023-04524-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The importance of assessing venous congestion in ICU patients is widely acknowledged, but its study is hampered by the lack of a practical evaluation tool. The Venous Excess Ultrasound Grading System (VExUS), based on a semi-quantitative combined ultrasound assessment, has been associated with acute kidney injury (AKI) in cardiac ICU patients. The objectives of this study were to assess the prevalence of congestion using VExUS in general ICU patients, and to evaluate the association between VExUS, AKI and death. METHODS This prospective, observational study included adult patients within 24 h of ICU admission. VExUS and hemodynamic parameters were measured four times during the ICU stay: within 24 h of ICU admission, after day 1 (between 24 and 48 h), after day 2 (between 48 and 72 h), and last day of ICU stay. The prevalence of AKI during the first week in ICU and 28-day mortality were assessed. RESULTS Among the 145 patients included, the percentage of patients with a VExUS score of 2 (moderate congestion) and 3 (severe congestion) was 16% and 6%, respectively. The prevalence did not change over the study period. There was no significant association between admission VExUS scores and AKI (p = 0.136) or 28-day mortality (p = 0.594). Admission VExUS ≥ 2 was not associated with AKI (OR 0.499, CI95% 0.21-1.17, p = 0.109) nor 28-day mortality (OR 0.75, CI95% 0.2-2.8, p = 0.669). The results were similar for VExUS scores measured at day 1 and day 2. CONCLUSIONS In general ICU cohort the prevalence of moderate to severe venous congestion was low. Early assessment of systemic venous congestion using VExUS scores was not associated with the development of AKI or with 28-day mortality.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France.
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Pierre-Alain Bahr
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000, Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, 21000, Dijon, France
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