Assessing Venous Congestion in Heart Failure: A Review of Splanchnic, Cardiac, and Pulmonary Ultrasound: Part 2: Contrast-Enhanced Ultrasound and Shear Wave

Background: Heart failure (HF) is a systemic syndrome characterized by venous congestion, which critically involves the splanchnic circulation. Conventional assessment methods often lack sensitivity for early or regional congestion. Methods: We conducted a systematic review of studies utilizing contrast-enhanced ultrasound (CEUS) and shear wave elastography (SWE) to evaluate congestion in adult HF patients, synthesizing evidence up to July 2025. Results: The integrated evidence demonstrates that CEUS and SWE provide distinct, complementary quantitative data. CEUS acts as a functional pillar, detecting microvascular congestion through parameters like prolonged hepatic vein transit time. SWE serves as a structural pillar, quantifying tissue stiffness that correlates with central venous pressure, tracks decongestion, and independently predicts adverse outcomes. Together, they differentiate reversible hemodynamic congestion from irreversible fibrotic remodeling across the liver, spleen, kidneys, and heart. Conclusions: Integrating CEUS and SWE into a multi-parametric ultrasound framework provides a comprehensive, bedside assessment of systemic congestion in HF. This approach enhances early detection, improves risk stratification, and offers a potential tool for guiding and monitoring personalized decongestive therapy, representing a significant advancement in holistic HF management.