Thread by @NephroP

Break from difficult cases but the #VExUS #POCUS series continues....this time #heartfailure with classic images.
#tweetorial
1/ Pulsatile portal v - 100% pulsatility in this case with bidirectional flow. Note the waveform change (on top) with ⬆️ RAP (Tang. et al 2016) #IMPOCUS

2/ How does the normal portal vein Doppler #POCUS look like? - above the baseline (flow towards the transducer) and gently undulates. Like this 👇

3/ Here is the hepatic vein waveform from our #heartfailure patient. Looks biphasic indicating severe congestion like that of portal vein. #POCUS
Note the RAP meter on top from Tang, et al. again.

4/ How does normal hepatic vein waveform look like & what do different waves convey? Here is an excellent image showing the correlation of hepatic vein (HV) with EKG & JVP. Note that the 'V' wave can be above the baseline or below (may lead to confusion if u don't have EKG)

5/ Here is another amazing illustration showing the transformation of the waveform from normal to biphasic. #POCUS

Now coming to the IVC in our patient - big with little inspiratory collapse as expected. Max diameter ~3 cm. Again note the RAP meter on the top. As @ThinkingCC says, there is no need to do VExUS, if the IVC #POCUS does not suggest ⬆️RAP

Oh, forgot about renal vein Doppler. This slide gives an idea. We don't always get simultaneous arterial tracing but it helps to identify systole and diastole. Think I got these classic images from one of @WBeaubien 's articles. Anyways, note the RAP meter again. #POCUS

Finally, figure from the famous #VExUS #POCUS paper to consolidate everything. Link: ncbi.nlm.nih.gov/pmc/articles/P…

Going back to our patient again: Don't forget that gall bladder wall can be thickened in CHF (normally <3 mm). Don't label as cholecystitis unless the clinical picture suggests. Here it is ~7 mm. #POCUS

Hope I was able to put together a brief & decent overview of #VExUS Thanks for going through. Cc @ArgaizR @Thind888 @KalagaraHari @iceman_ex and other vexus fans.