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World J Clin Cases. Jul 6, 2026; 14(19): 119964
Published online Jul 6, 2026. doi: 10.12998/wjcc.119964
Venous excess ultrasound score detects systemic venous congestion in a left ventricular assist device patient: A case report
Fotios Dimitriadis, Dimitrios Elaiopoulos, Michalis Antonopoulos, Giorgos Konstantinou, Theodosia Maragkoulia, Paraskevi Salata, Maria Chronaki, Eleni Tzatzaki, Ioannis Vlahodimitris, Theodoros Pitsolis, Michail Zervos, Theodora Soulele, Michail Bonios, Themistoklis Chamogeorgakis, Stavros Dimopoulos
Fotios Dimitriadis, Dimitrios Elaiopoulos, Michalis Antonopoulos, Giorgos Konstantinou, Theodosia Maragkoulia, Paraskevi Salata, Maria Chronaki, Eleni Tzatzaki, Ioannis Vlahodimitris, Theodoros Pitsolis, Michail Zervos, Theodora Soulele, Stavros Dimopoulos, Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens 17674, Attikí, Greece
Michail Bonios, Department of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Attikí, Greece
Themistoklis Chamogeorgakis, 2nd Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Attikí, Greece
Co-first authors: Fotios Dimitriadis and Dimitrios Elaiopoulos.
Author contributions: Dimitriadis F and Elaiopoulos D conceptualized the study; Dimitriadis F and Dimopoulos S designed the methodology; Dimitriadis F, Dimopoulos S, and Elaiopoulos D validated the data; Dimitriadis F performed the formal analysis, investigation and provided resources; Antonopoulos M, Konstantinou G, Maragoulia T, Salata P, Chronaki Μ, Tzatzaki E, Vlahodimitris I, Pitsolis T, Zervos M, Soulele T, Bonios M, and Chamogeorgakis T curated the data; Dimitriadis F wrote the original draft; Dimitriadis F and Dimopoulos S reviewed and edited the manuscript; Dimopoulos S supervised the study and administered the project; and all authors have read and approved the final version of the manuscript.
AI contribution statement: Portions of this manuscript were edited using AI tools solely for language refinement. The authors carefully reviewed and verified all AI-assisted outputs and take full responsibility for the scientific content of the manuscript.
Informed consent statement: Written informed consent has been obtained from the patient to publish this paper.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this case report.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Stavros Dimopoulos, MD, PhD, Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, 356 Syggrou Av, Athens 17674, Attikí, Greece.
stdimop@gmail.com
Received: February 11, 2026
Revised: May 21, 2026
Accepted: June 10, 2026
Published online: July 6, 2026
Processing time: 141 Days and 11.3 Hours
BACKGROUND
Left ventricular assist devices (LVADs) are a well-known therapeutic option for patients with advanced heart failure. Pump speed directly influences ventricular dimensions, septal position, right ventricular (RV) loading conditions, and overall haemodynamics. Echocardiography remains crucial for the assessment of such patients, whereas the venous excess ultrasound score (VExUS) is an emerging bedside tool for evaluating systemic venous congestion.
CASE SUMMARY
A 45-year-old woman with advanced ischaemic cardiomyopathy was admitted to the intensive care unit after HeartMate 3 LVAD implantation. On the fourth postoperative day, she developed severe hypotension with low estimated pump flow and low pulsatility index (PI) while the LVAD was set at 5100 rpm. After an empiric 250 mL saline bolus, urgent transthoracic echocardiography showed a small left ventricular cavity, RV dilation, leftward septal shift, and features of ventricular interdependence. VExUS assessment demonstrated severe systemic venous congestion, with hepatic vein systolic flow reversal, marked portal vein pulsatility, and severely abnormal intrarenal venous Doppler flow. Based on combined echocardiographic, venous Doppler, and device findings, hypotension was attributed to suction-related ventricular interdependence and right-sided congestion rather than isolated hypovolaemia. LVAD speed was decreased from 5100 rpm to 4900 rpm, followed by rapid haemodynamic stabilisation, improved pump flow and PI, restoration of a midline septal position, and partial improvement in portal venous flow.
CONCLUSION
This case highlights the potential value of integrating VExUS with conventional echocardiography and LVAD parameter interpretation during postoperative haemodynamic instability. Serial venous Doppler assessment may help distinguish congestion-related ventricular interdependence from true hypovolaemia and support individualized adjustment of pump speed and fluid strategy. Further validation in LVAD populations is required.
Core Tip: In left ventricular assist device (LVAD)-supported patients, hypotension and low-flow alarms do not necessarily indicate hypovolaemia. This case highlights how integrating transthoracic echocardiography with venous excess ultrasound score (VExUS) can help identify suction-associated ventricular interdependence with systemic venous congestion and guide timely LVAD speed optimisation rather than unnecessary fluid loading. VExUS should be interpreted as an adjunctive bedside tool within the broader clinical, echocardiographic, and device-parameter context. Serial venous Doppler reassessment may further support bedside monitoring of congestion and response to interventions during postoperative haemodynamic instability. Further validation is required before routine implementation in LVAD patients.
