Portal vein pulsatility index is a more important indicator than congestion index in the clinical evaluation of right heart function

Clinical impact of portal vein pulsatility on the prognosis of hospitalized patients with acute heart failure

BACKGROUND

Heart failure (HF) causes extracardiac organ congestion, including in the hepatic portal system. Reducing venous congestion is essential for HF treatment, but evaluating venous congestion is sometimes difficult in patients with chronic HF. The portal vein (PV) flow pattern can be influenced by right atrial pressure. Ultrasound images of the PV are quite easy to obtain and are reproducible among sonographers. However, the association between PV pulsatility and the condition of HF remains unclear. We hypothesize that PV pulsatility at discharge reflects the condition of HF.

AIM

To evaluate the usefulness of PV pulsatility as a prognostic marker for hospitalized patients with acute HF.

METHODS

This observational study was conducted from April 2016 to January 2017 and April 2018 to April 2019 at Shinko Hospital. We enrolled 56 patients with acute HF, and 17 patients without HF served as controls. PV flow velocity was measured by ultrasonography on admission and at discharge. We calculated the PV pulsatility ratio (PVPR) as the ratio of the difference between the peak and minimum velocity to the peak velocity. The primary endpoint was cardiac death and HF re-hospitalization. The observation period was 1 year from the first hospitalization. The Kaplan-Meier method was used to determine the stratified composite event-free rates, and the log-rank test was used for comparisons between groups.

RESULTS

On admission, the PVPR was significantly higher in patients with acute HF than controls (HF: 0.29 ± 0.20 vs controls: 0.08 ± 0.07, P < 0.01). However, the PVPR was significantly decreased after the improvement in HF (admission: 0.29 ± 0.20 vs discharge: 0.18 ± 0.15, P < 0.01) due to the increase in minimum velocity (admission: 12.6 ± 4.5 vs discharge: 14.6 ± 4.6 cm/s, P = 0.03). To elucidate the association between the PVPR and cardiovascular outcomes, the patients were divided into three groups according to the PVPR tertile at discharge (PVPR-T1: 0 ≤ PVPR ≤ 0.08, PVPR-T2: 0.08 < PVPR ≤ 0.21, PVPR-T3: PVPR > 0.21). The Kaplan-Meier analysis showed that patients with a higher PVPR at discharge had the worst prognosis among the groups.

CONCLUSION

PVPR at discharge reflects the condition of HF. It is also a novel prognostic marker for hospitalized patients with acute HF.

Utility of portal vein pulsatility fraction in patients undergoing corrective surgery for tetralogy of Fallot

BACKGROUND

Right ventricle dysfunction is common after corrective surgery for tetralogy of Fallot and is associated with significant morbidity and mortality. We aimed to determine whether an increased portal vein pulsatility fraction (PVPF) was associated with worse clinical outcomes.

METHODS

In a prospective, observational, single-centre study, PVPF and other commonly used parameters of right ventricle function were assessed in patients of all ages undergoing corrective surgery for tetralogy of Fallot intraoperatively, with transesophageal echocardiography, before and after bypass, and post-operatively, with transthoracic echocardiography, at days 1, 2, at extubation, and at ICU discharge. The correlation was tested between PVPF and mechanical ventilation duration, prolonged ICU stay, mortality, and right ventricle function.

RESULTS

The study included 52 patients, and mortality was in 3 patients. PVPF measurement was feasible in 96% of the examinations. PVPF in the immediate post-operative period had sensitivity of 73.3% and a specificity of 74.3% in predicting the occurrence of the composite outcome of prolonged mechanical ventilation, ICU stay, or mortality. There was a moderate negative correlation of PVPF with right ventricle fractional area change and right ventricle global longitudinal strain (r = -0.577, p < 0.001 and r = 0.465, p < 0.001, respectively) and a strong positive correlation with abnormal hepatic vein waveform (rho = 0.749, p < 0.001).

CONCLUSION

PVPF is an easily obtainable bedside parameter to assess right ventricular dysfunction and predict prolonged mechanical ventilation, prolonged ICU stay, and mortality.

Evaluation of Portal, Splenic, and Hepatic Vein Flows in Children Undergoing Congenital Heart Surgery

OBJECTIVE

Little is known about changes in portal, splenic, and hepatic vein flow patterns in children undergoing congenital heart surgery. This study aimed to determine the characteristics of portal, splenic, and hepatic vein flow patterns using ultrasonography in children undergoing cardiac surgery.

DESIGN

Single-center, prospective observational study.

SETTING

Tertiary children's hospital, operating room.

PARTICIPANTS

Children undergoing cardiac surgery.

MEASUREMENT AND MAIN RESULTS

The authors obtained ultrasound data from the heart, inferior vena cava, portal, splenic, and hepatic veins before and after surgeries. In the biventricular group, which included children with atrial and ventricular septal defects and pulmonary stenosis (n = 246), the portal pulsatility index decreased from 38.7% to 25.6% (p < 0.001) after surgery. The preoperative portal pulsatility index was significantly higher in patients with pulmonary hypertension (43.3% v 27.4%; p < 0.001). In the single-ventricle group (n = 77), maximum portal vein flow velocities of Fontan patients were significantly lower (13.5 cm/s) compared with that of patients with modified Blalock-Taussig shunt (19.7 cm/s; p = 0.035) or bidirectional cavopulmonary shunt (23.1 cm/s; p < 0.001). The cardiac index was inversely correlated with the portal pulsatility index in the bidirectional cavopulmonary shunt and Fontan circulation. (β = -5.693, r² = 0.473; p = 0.001) The portal pulsatility index was correlated with splenic venous pulsatility and hepatic venous atrial reverse flow velocity in biventricular and single-ventricle groups.

CONCLUSIONS

The characteristics of venous Doppler patterns in the portal, splenic, and hepatic veins differed according to congenital heart disease. Further studies are required to determine the association between splanchnic venous Doppler findings and clinical outcomes in this population.

The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting

Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.

Portal Vein Pulsatility Index as a Potential Risk of Venous Congestion Assessed by Magnetic Resonance Imaging: A Prospective Study on Healthy Volunteers

High values of the portal vein pulsatility index (PI) have been associated with adverse outcomes in perioperative or critically ill patients. However, data on dynamic changes of PI related to fluid infusion are scarce. We aimed to determine if dynamic changes in PI are associated with the fluid challenge (FC). To address this challenge, we conducted a prospective single-center study. The population study included healthy subjects. FC consisted in the administration of 500 ml of Ringer lactate infusion over 5 min. The portal blood flow and PI were assessed by magnetic resonance imaging. The responsiveness to FC was defined as an increase in the cardiac stroke volume of at least 10% as assessed by echocardiography. We included 24 healthy volunteers. A total of fourteen (58%) subjects were responders, and 10 (42%) were non-responders. In the responder group, FC induced a significant increase in portal blood flow from 881 (762–1,001) at the baseline to 1,010 (778–1,106) ml min⁻¹ (p = 0.005), whilst PI remained stable (from 31 [25–41] to 35 (25–42) %; p = 0.12). In the non-responder group, portal blood flow remained stable after FC (from 1,042 to 1,034 ml min⁻¹; p = 0.084), whereas PI significantly increased from 32 (22–40) to 48% *(25–85) after FC (p = 0.027). PI was negatively correlated to portal blood flow (Rho coefficient = −0.611; p = 0.002). To conclude, PI might be a sensitive marker of early congestion in healthy subjects that did not respond to FC. This finding requires further validation in clinical settings with a larger sample size.

Ultrasonographic characteristics of the portal venous system of 37 healthy, unsedated, student-owned cats: A prospective study

OBJECTIVE

The aim of this study was to determine portal vein and divisional branch diameters and portal vein velocities in healthy, unsedated cats, using B-mode and Doppler ultrasound.

ANIMAL

Thirty-seven healthy, adult cats, all owned by students.

PROCEDURE

Enrollment of cats in the study was done prospectively. Ultrasonographic imaging in both the longitudinal and transverse planes was assessed, with all examinations and measurements done by the same person. The assessment included the following 3 sites: extra-hepatic portion of the portal vein, intra-hepatic branches of the portal vein, and the aorta at the level of the porta hepatis. The Shapiro-Wilk test was used for normality and P < 0.05 was used to define statistical significance.

RESULTS

Both the extra-hepatic portion of the portal vein and the porta hepatis were identified in all 37 cats (100%), whereas the aorta was recorded in 31 (84%), and the left and right intra-hepatic branches of the portal vein were seen in 29 (78%). Pulsed-wave Doppler ultrasound of the portal vein was obtained in 32 cats (86%). In longitudinal view, average maximal diameter of the extra-hepatic portal vein was 3.6 mm (± 0.7 mm), and the mean portal flow velocity was 14.6 cm · s (± 4.3 cm · s). In transverse view, average maximal diameter was 4.8 mm (± 0.8 mm) for the extra-hepatic portal vein, and 3.1 mm (± 0.8 mm) and 2.6 mm (± 0.7 mm) for the left and right intra-hepatic branches, respectively. The portal-vein-to-aorta ratio averaged 1.2 (± 0.2).

CONCLUSION

This study produced sonographic data of the portal venous system in healthy, conscious adult cats, which may be useful during investigation of liver diseases, including congenital and acquired liver diseases.

Portal Vein Pulsatility as a Dynamic Marker of Venous Congestion Following Cardiac Surgery: An Interventional Study Using Positive End-Expiratory Pressure

We aimed to assess variations in the portal vein pulsatility index (PI) during mechanical ventilation following cardiac surgery. Method. After ethical approval, we conducted a prospective monocentric study at Amiens University Hospital. Patients under mechanical ventilation following cardiac surgery were enrolled. Doppler evaluation of the portal vein (PV) was performed by transthoracic echography. The maximum velocity (VMAX) and minimum velocity (VMIN) of the PV were measured in pulsed Doppler mode. The PI was calculated using the following formula (VMAX − VMIN)/(VMax). A positive end-expiratory pressure (PEEP) incremental trial was performed from 0 to 15 cmH₂O, with increments of 5 cmH₂O. The PI (%) was assessed at baseline and PEEP 5, 10, and 15 cmH₂O. Echocardiographic and hemodynamic parameters were recorded. Results. In total, 144 patients were screened from February 2018 to March 2019 and 29 were enrolled. Central venous pressure significantly increased for each PEEP increment. Stroke volumes were significantly lower after PEEP incrementation, with 52 mL (50–55) at PEEP 0 cmH₂O and 30 mL (25–45) at PEEP 15 cmH₂O, (p < 0.0001). The PI significantly increased with PEEP incrementation, from 9% (5–15) at PEEP 0 cmH₂O to 15% (5–22) at PEEP 5 cmH₂O, 34% (23–44) at PEEP 10 cmH₂O, and 45% (25–49) at PEEP 15 cmH₂O (p < 0.001). Conclusion. In the present study, PI appears to be a dynamic marker of the interaction between mechanical ventilation and right heart pressure after cardiac surgery. The PI could be a useful noninvasive tool to monitor venous congestion associated with mechanical ventilation.

Comprehensive Assessment of Fluid Status by Point-of-Care Ultrasonography

The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-care ultrasonography (POCUS) is emerging as a valuable, noninvasive, bedside diagnostic tool for objective evaluation of physiologic and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function and quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography, provides additional quantitative information, including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage, adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient's hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function and pulmonary and venous congestion using POCUS and review relevant literature.

Comprehensive Assessment of Fluid Status by Point-of-Care Ultrasonography

The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-care ultrasonography (POCUS) is emerging as a valuable, noninvasive, bedside diagnostic tool for objective evaluation of physiologic and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function and quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography, provides additional quantitative information, including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage, adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient's hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function and pulmonary and venous congestion using POCUS and review relevant literature.

VExUS Nexus: Bedside Assessment of Venous Congestion

Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion.

Portal venous pulsatility fraction, a novel transesophageal echocardiographic marker for right ventricular dysfunction in cardiac surgical patients

Background:

Right ventricular (RV) has a vital role in maintaining optimal tissue perfusion. Assessment of portal venous flow characteristics can be alternative and emerging technique to assess RV function.

Aims:

To investigate if portal venous pulsatility fraction (PF) could serve as effective and complementary tool in identifying RV dysfunction.

Materials and Methods:

Thirty adult patients aged 18-65 years undergoing cardiac surgery under general anesthesia were enrolled in study. Intraoperative transesophageal echocardiographic examination was performed. Tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (EF), and portal vein flow pulsatility were assessed. Portal vein PF was used to quantify degree of pulsatility.

Results:

Portal vein was demonstrated in 27 patients (90%). 27 values of portal vein PF, RV EF, FAC, and TAPSE were analyzed. Portal vein PF demonstrated significant linear correlation with TAPSE (r = −0.55, P = 0.003), RV FAC (r = −0.44, P = 0.02), and RV EF (r = −0.53, P = 0.004). ROC curve was constructed to calculate sensitivity and specificity of portal vein PF for assessing RV function. Portal vein PF value of ≥45% indicated RV dysfunction with sensitivity of 92.3%, specificity of 71.4%, positive predictive value of 75%, and negative predictive value of 90.9%. Area under ROC curve was 0.819 (95% confidence interval = 0.624 – 0.939, P = 0.0006).

Conclusion:

Portal vein PF is simple and feasible method for assessment of RV function. It complements the existing echocardiographic measures to diagnose RV dysfunction.

Focused ultrasonography for septic shock resuscitation

PURPOSE OF REVIEW

Severe sepsis with septic shock is the most common cause of death among critically ill patients. Mortality has decreased substantially over the last decade but recent data has shown that opportunities remain for the improvement of early and targeted therapy. This review discusses published data regarding the role of focused ultrasonography in septic shock resuscitation.

RECENT FINDINGS

Early categorization of the cardiovascular phenotypes with echocardiography can be crucial for timely diagnosis and targeted therapy of patients with septic shock. In the last few years, markers of volume status and volume responsiveness have been investigated, serving as valuable tools for targeting volume therapy in the care of both spontaneously breathing and mechanically ventilated patients. In tandem, investigators have highlighted findings of extravascular volume with ultrasonographic evaluation to compliment de-escalation of resuscitation efforts when appropriate. Furthermore, special attention has been given to resuscitation efforts of patients in septic shock with right ventricular failure.

SUMMARY

Severe sepsis with septic shock is an insidious disease process that continues to take lives. In more recent years, data have emerged suggesting the utility of bedside ultrasonography for early cardiovascular categorization, goal directed resuscitation, and appropriate cardiovascular support based on its changing phenotypes.

Hepatic and splenic sonographic and sonoelastographic findings in pulmonary arterial hypertension

Purpose

The aim of this study was to evaluate the associations of sonographic and sonoelastographic parameters with clinical cardiac parameters, as well as to assess their value in predicting survival in patients with pulmonary arterial hypertension (PAH).

Methods

Thirty-six patients with PAH and normal liver function were prospectively enrolled in this prospective study along with 26 healthy controls, all of whom underwent ultrasound and point shear wave elastography examinations. Additionally, the portal vein pulsatility index (PVPI), inferior vena cava collapsibility index, and clinical cardiac variables were obtained in PAH patients. The values of hepatic (LV_s) and splenic shear wave velocity (SV_s) were compared between PAH patients and controls. The relationships between all sonographic and clinical parameters in the PAH patients were analyzed. Furthermore, their prognostic value in predicting survival was investigated.

Results

LV_s values in PAH patients (median, 1.62 m/s) were significantly higher than in controls (median, 0.99 m/s), while no significant difference was observed in SV_s values. Patients with higher grades of tricuspid regurgitation (TR) had significantly different values of PVPI (P=0.010) and sonoelastographic parameters (P<0.001 for LV_s and P=0.004 for SV_s) compared to those with less severe TR. Tricuspid annular plane systolic excursion values were the only investigated parameter found to be associated with survival (hazard ratio, 0.814; 95% confidence interval, 0.694 to 0.954; P=0.011).

Conclusion

Our results demonstrated a direct association between cardiac congestion (i.e., the severity of TR) and liver stiffness, which should be kept in mind during the assessment of fibrosis in patients with PAH.

The Nephrologist as an Ultrasonographer

Ultrasonography is increasingly being used in the practice of nephrology, whether it is for diagnosis or management of acute or chronic kidney dysfunction, until progression to end-stage kidney disease, including preoperative assessment, access placement, and diagnosis and management of dysfunctional hemodialysis access. Point-of-care ultrasounds are also being used by nephrologists to help manage volume status, especially in patients admitted to the intensive care units, and more recently, for guiding fluid removal in the outpatient dialysis units. Fundamental knowledge of sonography has become invaluable to the nephrologist, and performance and interpretation of ultrasound has now become an essential tool for practicing nephrologists to provide patient-centered care, maximize efficiency, and minimize fragmentation of care. This review will address the growing role of ultrasonography in the management of a patient with CKD from the point of initial contact with the nephrologist throughout the spectrum of kidney disease and its consequences.

Can regional cerebral oxygen saturation guide red blood cell transfusion in high risk cardiac surgery?

INTRODUCTION

Cardiac surgery (CS) is associated with a significant use of blood products. The aim of this study was to evaluate the effect of red blood cells concentrates (RBC) transfusion on regional cerebral oxygen saturation (SrO₂) in patients undergoing CS with additive EuroSCORE I > 6.

MATERIAL AND METHODS

This is a prospective descriptive study. Patients with additive EuroSCORE I > 6 undergoing CS with extracorporeal circulation were included in the study. The demographic values, perioperative complications, hospital/ICU length of stay (LOS), as well as the preinduction baseline SrO₂values, the lowest SrO₂ value during surgery, number of blood products transfused, hemoglobine (HB) and pre and postransfusional SrO2 values were recorded, and events of significant decrease in SrO₂ below 20% of basal value or decrease below 50%. We considered responders those who had an increase post-transfusion SrO₂ at least 20% of pre-transfusion value, an increase of standar deviation (7.9) or an increase up to basal SrO₂.

RESULTS

Data from 57 patients were collected. The average additive EuroSCORE I was 7.4 (SD 2.6) and the EuroSCORE II was 6.1 (SD 7.4). 52% were male. 35.1% of patients received intraoperative transfusion of at least one unit of RBC. The overall mortality was 8.7% (N = 5). During surgery 29.8% of the overall sample presented a decrease of more than 20% of baseline SrO2 or a value lower than 50%. Patients with a significant decrease in SrO2 presented a higher rate of perioperative complications (P=0.04) and longer ICU-LOS 4.3 (SD 3.6) vs. 6.8 (SD 8.2) days (P=0.01) and hospital LOS 10.1 (SD 3.1) vs. 14.2 (SD 9.4) days (P=0.01). Pretransfusional HB was 7.4 (SD 0.8) mg/dl and postransfusional value was 8.4 (SD 0.8) (P =0.00). Pretransfusional SrO2 was 59 (SD 8.6) and increased non- significantly after RBC transfusion to 61.1 (SD 7.9) (P=0.1). Only 6 patients out of 21 could be considered responders. There were no significant differences in morbidity, mortality or LOS between responders and non-responders.

DISCUSSION

In our population a non statistically significant increase in SrO2 was observed after RBC transfusion. When considering responders few patients were identified by SrO₂. In conclusion SrO₂ might not be reliable triger to decide transfusion.

FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease

OBJECTIVE

As the population of patients with Fontan circulation surviving into adulthood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper intervention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population.

DESIGN

The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system.

RESULTS

In our cohort, 100% of patients had fibrosis with 36% demonstrating advanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver biopsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis.

CONCLUSION

This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.

Abdominal contributions to cardiorenal dysfunction in congestive heart failure

Current pathophysiological models of congestive heart failure unsatisfactorily explain the detrimental link between congestion and cardiorenal function. Abdominal congestion (i.e., splanchnic venous and interstitial congestion) manifests in a substantial number of patients with advanced congestive heart failure, yet is poorly defined. Compromised capacitance function of the splanchnic vasculature and deficient abdominal lymph flow resulting in interstitial edema might both be implied in the occurrence of increased cardiac filling pressures and renal dysfunction. Indeed, increased intra-abdominal pressure, as an extreme marker of abdominal congestion, is correlated with renal dysfunction in advanced congestive heart failure. Intriguing findings provide preliminary evidence that alterations in the liver and spleen contribute to systemic congestion in heart failure. Finally, gut-derived hormones might influence sodium homeostasis, whereas entrance of bowel toxins into the circulatory system, as a result of impaired intestinal barrier function secondary to congestion, might further depress cardiac as well as renal function. Those toxins are mainly produced by micro-organisms in the gut lumen, with presumably important alterations in advanced heart failure, especially when renal function is depressed. Therefore, in this state-of-the-art review, we explore the crosstalk between the abdomen, heart, and kidneys in congestive heart failure. This might offer new diagnostic opportunities as well as treatment strategies to achieve decongestion in heart failure, especially when abdominal congestion is present. Among those currently under investigation are paracentesis, ultrafiltration, peritoneal dialysis, oral sodium binders, vasodilator therapy, renal sympathetic denervation and agents targeting the gut microbiota.