Assessment of Congestion in Heart Failure Using VExUS: Current Evidence, Limitations and Clinical Perspectives

Background: Systemic venous congestion is a key driver of organ dysfunction in heart failure (HF), yet accurate non-invasive quantification remains challenging. Recognizing residual congestion is critical, since it predicts HF readmissions and mortality. Traditional assessments (physical exam, jugular venous pressure, inferior vena cava [IVC] size) are imprecise. The Venous Excess Ultrasound Score (VExUS) is a semi-quantitative point-of-care ultrasound (POCUS) protocol that integrates IVC diameter with Doppler flow patterns in the hepatic, portal and intrarenal veins to grade systemic venous overload. Methods: We conducted a narrative review of literature (2018-2025) regarding the usefulness of VExUS in HF, covering congestion pathophysiology, clinical evidence (hemodynamic correlations, organ dysfunction, outcomes), potential applications, integration with lung ultrasound, echocardiography and biomarkers, limitations of its assessment and future directions. Results and Discussions: In HF, elevated right atrial pressure causes venous congestion. VExUS integrates IVC diameter with Doppler waveforms of hepatic, portal, and intrarenal veins to grade congestion. Emerging evidence shows higher VExUS grades correlate with elevated filling pressures, renal dysfunction, and worse outcomes. Its use may guide diuretic therapy, aid discharge planning, and monitor outpatient congestion, especially when combined with lung ultrasound and biomarkers. However, VExUS has limitations: it is technical and operator-dependent. Importantly, large trials validating VExUS-guided management are lacking. Future directions include AI-driven automation of Doppler analysis and integration with multimodal congestion monitoring to provide a comprehensive congestion assessment. Conclusions: VExUS is a promising noninvasive tool for quantifying congestion in HF. Higher grades are associated with organ dysfunction and poor prognosis. Incorporating this technique into HF care may improve congestion-guided therapy, but large-scale validation is required before routine use.