VExUS in Mechanical Circulatory Support: Unveiling the Role of Doppler Ultrasound in Assessing Venous Congestion

Persistent congestion in decompensated heart failure predicts poor outcomes. The Venous Excess Ultrasound (VExUS) score, which integrates hepatic, portal, and intrarenal Doppler waveforms, provides a dynamic, noninvasive measure of venous congestion and outperforms right atrial pressure alone. Its utility during mechanical circulatory support remains largely unexplored. We report a case of right ventricular failure requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and intra-aortic balloon pump (IABP). Despite changes in arterial waveform with IABP settings, venous Doppler signals remained stable, suggesting minimal impact on congestion. In contrast, clamping the ECMO circuit led to marked worsening of portal and intrarenal waveforms, highlighting the drainage cannula's role in right-sided offloading. Hepatic vein Doppler remained unchanged due to severe tricuspid regurgitation (TR). This case illustrates the value of VExUS in monitoring venous congestion during advanced cardiac support and its potential in guiding decongestion strategies, weaning decisions, and right heart support. Further research is needed to validate these observations.