Applications of Venous Excess Ultrasound Score (VExUS) in Volume Status Assessment in Patients With Acute Decompensated Heart Failure and Cardiorenal Syndrome

Accurate assessment of volume status and venous congestion is essential in the management of congestive heart failure (CHF), particularly in patients with cardiorenal syndrome (CRS). Traditional approaches, including physical examination, laboratory biomarkers, and noninvasive hemodynamic monitoring, have notable limitations in reliably detecting venous congestion. The Venous Excess Ultrasound (VExUS) score, introduced in 2020, offers a noninvasive and widely available method to evaluate systemic congestion by integrating Doppler assessment of the inferior vena cava, hepatic, portal, and intrarenal veins. This narrative review summarizes the current evidence supporting the utility of VExUS in CHF and CRS, highlighting its diagnostic performance, advantages, and challenges. Studies demonstrate that VExUS correlates strongly with right atrium pressure and outperforms individual ultrasound or biochemical markers in predicting elevated filling pressures and acute kidney injury. Its application may help detect subclinical renal congestion and guide diuretic therapy before irreversible renal injury occurs. Despite these strengths, the technique has limitations, including technical complexity, operator dependence, and potential inaccuracy in the presence of liver disease or significant tricuspid regurgitation. Overall, VExUS represents a promising and widely accessible tool that enhances risk stratification and treatment optimization in CHF and CRS. Further prospective studies are needed to standardize image acquisition, validate its prognostic value across diverse populations, and define its role within heart failure management algorithms and diuretic-guided therapy protocols.