case_images: PMC11044922_01
case_images: 1: Radiology-performed scan images demonstrating a dilated inferior vena cava (approximately 3 cm), S-wave reversal on hepatic vein Doppler and a pulsatile portal vein (below-the-baseline blebs represent flow reversal).
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case_images: This was evidenced by a dilated inferior vena cava (IVC) with an approximate anteroposterior diameter of 3 cm, systolic (S-wave) reversal in the hepatic vein flow, and a pulsatile portal vein with some flow reversal (Figure 1). 
case_images: 2: Venous excess ultrasound grading: When the diameter of the inferior vena cava is > 2 cm, three grades of congestion are defined based on the severity of abnormalities on hepatic, portal, and renal parenchymal venous Doppler. Hepatic vein Doppler is considered mildly abnormal when the systolic (S) wave is smaller than the diastolic (D) wave, but still below the baseline; it is considered severely abnormal when the S-wave is reversed. Portal vein Doppler is considered mildly abnormal when the pulsatility is 30% to 50%, and severely abnormal when it is >= 50%. Asterisks represent points of pulsatility measurement. Renal parenchymal vein Doppler is mildly abnormal when it is pulsatile with distinct S and D components, and severely abnormal when it is monophasic with D-only pattern. Adapted from NephroPOCUS.com with permission.
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case_images: These sonographic findings are consistent with VExUS grade 3 (Figure 2).
case_images: Formal echocardiogram images demonstrating (A) interventricular septal flattening on parasternal short axis view and (B) qualitatively severe tricuspid regurgitation.
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case_images: A formal echocardiogram demonstrated reduction of left ventricular ejection fraction from a baseline of 37% to ~30%, new right ventricular enlargement with interventricular septal flattening (D-sign), and severe functional tricuspid regurgitation, suggestive of fluid overload (Figure 3).
case_images: POCUS images demonstrating S<D pattern on hepatic vein Doppler and a normal appearing (pulsatility <30%) portal vein waveform.
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case_images: A simultaneous EKG tracing was used to avoid errors in misidentification of the waves (Figure 4).
case_images: Inferior vena cava ultrasound short axis demonstrating the maximal anteroposterior diameter (approximately 2.1 cm) and inspiratory collapse.
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case_images: The IVC maximal diameter improved to approximately 2.1 cm, with >50% inspiratory collapse with an estimated right atrial pressure of 8 mmHg (Figure 5).
case_images: Inferior vena cava ultrasound short axis demonstrating the maximal anteroposterior diameter (approximately 1.9 cm) and inspiratory collapse.
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case_images: Follow up POCUS after the 3rd session demonstrated further improvement in IVC size (<2 cm), and collapsibility consistent with an estimated right atrial pressure of 3 mmHg (Figure 6).
case_images: POCUS images demonstrating almost equal S and D waves on hepatic vein Doppler and a normal (pulsatility <30%) appearing portal vein waveform.
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case_images: Hepatic vein Doppler demonstrated further improvement in S-wave amplitude to near-normal configuration, and the portal vein remained continuous (Figure 7).