Lung and Venous Excess Ultrasound Correlation With Intracardiac Pressures Before and After Decongestion in Critically Ill Patients With Acute Decompensated Heart Failure

IMPORTANCE: Venous congestion contributes to multiple organ dysfunction and mortality in critically ill patients. The venous excess ultrasound (VExUS) and lung ultrasound scores have been shown to reflect cardiac filling pressures, but their ability to track hemodynamic changes during decongestion in critically ill patients remains unclear. OBJECTIVES: To determine the correlation of lung ultrasound and VExUS scores with intracardiac filling pressures before and after decongestion in critically ill patients with acute decompensated heart failure. DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective single-center observational pilot study of adults admitted to the cardiac intensive care and who underwent pulmonary artery catheter placement for hemodynamic-guided decongestion. We performed paired measurements of VExUS grade, simplified lung ultrasound (sLUS) scores, and calculated the renal venous stasis index (RVSI) before and after decongestion and assessed for changes and correlation with right atrial pressure (RAP) and pulmonary artery occlusion pressure (PAOP). MEASUREMENTS AND MAIN RESULTS: Twenty patients underwent 40-paired assessments. After decongestion, a significant reduction in RAP (-9.2 mm Hg; 95% CI, -12.4 to -5.9 mm Hg; p ≤ 0.0001) and PAOP (-12.8 mm Hg; 95% CI, -16.6 to -9.1 mm Hg; p ≤ 0.0001) mirrored reductions in VExUS grades (-1.3; 95% CI, -1.8 to -0.7; p = 0.0002), portal vein pulsatility fraction (-19.9%; 95% CI, -34.1 to -5.6; p = 0.0075), RVSI (-0.19; 95% CI, -0.38 to 0; p = 0.04), and sLUS (-11 points; 95% CI, -14.2 to -8.5; p ≤ 0.0001). VExUS grades and portal vein pulsatility fraction correlated with RAP both before (p = 0.02 and p ≤ 0.003) and after (p = 0.01 and p = 0.001) decongestion, but neither correlated with PAOP. sLUS correlated with PAOP at baseline (ρ = 0.82; p < 0.001) and following decongestion (ρ = 0.59; p = 0.05), while showing no significant correlation with RAP pre-decongestion. CONCLUSIONS AND RELEVANCE: In critically ill patients with acute decompensated heart failure, we observed changes in VExUS and sLUS scores with decongestion which mirrored changes in intracardiac pressures. The portal vein pulsatility fraction had the higher reproducibility of the VExUS subcomponents. These findings support the role of VExUS and sLUS in hemodynamic monitoring of decongestion in critically ill patients with acute decompensated heart failure.