Modified Venous Excess Ultrasound: A Dynamic Tool to Predict Mortality in Acute Decompensated Heart Failure

Quantifying systemic venous congestion in acute decompensated heart failure (ADHF) is challenging. The Venous Excess Ultrasound (VExUS) score has emerged as a noninvasive tool for assessing venous congestion. Although higher VExUS values are linked to cardiorenal syndrome, its prognostic role in ADHF remains unclear. This study evaluated whether repeated VExUS measurements, obtained at 2 time points, predict in-hospital mortality in ADHF.

In this prospective cohort study, 104 patients with ADHF and left ventricular ejection fraction <50% were admitted to a cardiovascular intensive care unit between October 2022 and January 2024. Modified VExUS was assessed within 24 hours of admission and repeated at 72 hours using a modified protocol (mVExUS). ΔVExUS was defined as the 72-hour score minus the baseline score; improvement was defined as ΔVExUS ≥1. Complementary point-of-care ultrasound (POCUS) parameters and clinical markers of decongestion were also evaluated. Of the total, 97 patients had complete follow-up and were included in the ΔVExUS analysis. The primary outcome was in-hospital mortality.

Patients with ΔVExUS ≥1 had greater urine output, more pronounced weight loss, and greater reduction in serum creatinine and clinical congestion score (all P < .05). In-hospital mortality was significantly lower in patients with mVExUS improvement (11.1% vs 36.4%, P = .007). ΔVExUS ≥ 1 remained independently associated with lower in-hospital mortality after adjustment for clinical and echocardiographic variables (adjusted odds ratio, 0.31; 95% CI, 0.14-0.68; P = .004). In multivariable analysis using least absolute shrinkage and selection operator regression, ΔVExUS emerged as an independent predictor of in-hospital mortality (odds ratio, 0.32; 95% CI, 0.13-0.74).

A reduction of ≥1 point in the mVExUS score over the first 72 hours (ΔVExUS ≥ 1) was independently associated with lower in-hospital mortality and was accompanied by favorable clinical and laboratory markers of decongestion. This is the first study to identify ΔVExUS as a dynamic prognostic marker in ADHF, reinforcing its value as a practical tool for routine bedside application. These findings support the incorporation of repeated mVExUS assessments into standard practice to enhance risk stratification in patients with ADHF.