case_images: PMC9994295_01
case_images: Venous Doppler images at the time of initial POCUS scan demonstrating severe congestive pattern in hepatic, portal, and renal parenchymal veins. There is flow reversal during systole (flow away from the heart) in all the three veins. S = systolic wave; D = diastolic wave. Hemodynamic circuit illustration licensed fromshutterstock .
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case_images: Portal vein Doppler revealed 100% pulsatility with flow reversal during systole and intra-renal waveform showed flow only during diastole, i.e., only D-wave below the baseline (Figure 1).
case_images: Illustration showing the natural history of venous Doppler waveforms with increasing right atrial pressure. Dilatation of the inferior vena cava (typically >2 cm) usually precedes these changes. S = systolic wave, D = diastolic wave. Asterisks on the portal vein waveform indicate the highest and lowest amplitudes during a given cardiac cycle used to calculate percentpulsatility. Note that the normal portal vein waveform is above the baseline and the renal is below, which reflects the direction of blood flow towards and away from the transducer, respectively.
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case_images: Figure 2 illustrates the normal Doppler waveforms and their transformation with elevated right atrial pressure.
case_images: Changes in portal vein waveform in response to decongestive therapy. Note that the systolic flow reversal has disappeared initially followed by gradual decrease inpulsatility.
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case_images: The portal vein waveform was almost normalized during this period (Figure 3), though hepatic and intra-renal vein continued to show congestive pattern albeit with subtle changes suggesting improvement in right atrial pressures.
case_images: Small inferior vena cava and normalized venous Doppler waveforms following decongestive therapy. Hepatic waveform shows both S and D components below the baseline in most cardiac cyclesand portal and renal waveforms are continuous. Note that the patient had atrial fibrillation at the time of this scan, which decreases the amplitude of S wave.
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case_images: IVC as well as normalization of all the venous Doppler waveforms (online Video S1, Figure 4), indicating the resolution of the venous congestion. In addition, lung ultrasound demonstrated A-line pattern in the sono-auscultated zones.