European Heart Journal - Case Reports (2023) 7, 1–2 IMAGES IN CARDIOLOGY

https://doi.org/10.1093/ehjcr/ytad271 Cardiovascular imaging

Assessment of venous congestion in abdominal

compartment syndrome
Mario Andrés de Jesús Leal-Villarreal1 and Eduardo Argaiz 2
*
1
Instituto Nacional de Cardiología Ignacio Chavez; and 2Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico

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Received 3 January 2023; first decision 31 March 2023; accepted 5 June 2023; online publish-ahead-of-print 21 June 2023

A 72-year-old woman with a history of Heart Failure with
Preserved Ejection Fraction presented to the ED with worsening dys­
pnoea, hypoxaemia and abdominal distension. The patient was initially
treated with IV furosemide but later became oliguric and hypotensive.
Point-of-care ultrasound revealed a large volume of ascites and a col­
lapsed inferior vena cava (IVC) (see supplementary material online);
venous Doppler revealed non-pulsatile portal flow, continuous
intra-renal venous flow, and a non-pulsatile monophasic hepatic venous
flow (Figure 1A ). Abdominal compartment syndrome (ACS) was sus­
pected and confirmed by intravesical catheter measurement of
intra-abdominal pressure (IAP) at 22 mmHg. A therapeutic paracen­
tesis was performed with evacuation of 6 L of fluid. Immediately
after paracentesis, repeat ultrasound revealed a plethoric IVC, hepatic
vein Doppler with S wave amplitude lower than D wave, portal vein
pulsatility fraction of 48%, and a biphasic pattern on intra-renal vein
Doppler, consistent with persistent venous congestion (Figure 1B).
Repeat measurement of IAP was 8 mmHg. Given persistent venous
congestion, IV diuretics were continued. Over the next 48 h, urine
output improved, and serum creatinine normalized. Follow-up ultra­
sound examination revealed normalization of venous congestion para­
meters (Figure 1C). Cardiac induced ascites is usually treated with
diuretics; in this case, the finding of collapsed IVC suggested the diagnosis
of ACS and made paracentesis the preferred treatment. Despite the re­
moval of 6 L of fluid, Doppler findings of persistent venous congestion
after paracentesis reassured us to continue diuretic treatment.
Increased IAP leads to abdominal vessel compression and can result
in dampened Doppler waveforms masking the findings of venous con­
gestion. Dampened hepatic vein waveform has been reported during
pneumoperitoneum in laparoscopic surgery. We report for the first
time the effects of ACS on venous Doppler in the presence of venous
congestion. In conclusion, this case underscores an important caveat in
the interpretation of venous Doppler waveforms in ACS.

Figure 1 Hepatic, portal, and intra-renal venous Doppler findings at the time of abdominal compartment syndrome diagnosis (A), immediately fol­
lowing large volume paracentesis (B), and following diuretic treatment for residual congestion (C ). *In the absence of electrocardiogram, intra-renal
venous Doppler arterial waveform can be used to identify systole and diastole. Hence, overlapping both hepatic vein and intra-renal Doppler tracings
(obtained consecutively and at the same sweep speed) allows us to delineate venous S and D waves.

* Corresponding author. Tel: +525554870900, Email: argaiz@tec.mx

Handling Editor: Giulia Elena Mandoli
Peer-reviewers: Albert Galyavich; Gavin Lewis
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits
non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
2 M.A.de Jesús Leal-Villarreal et al.
Lead author biography
Internist and Nephrology Fellow at
Instituto Nacional de Ciencias Médicas
y Nutrición Salvador Zubirán. Assistant
Profesor of Medicine at Tecnológico
de Monterrey, Escuela de Medicina y
Ciencias de la Salud. Board Member of
the Mexican Society of Echocardiography
SONECOM.
Supplementary material
Supplementary material is available at European Heart Journal – Case
Reports.
Consent: Study participant provided informed written consent prior
to manuscript submission.
Conflict of interest: ERA declares speaker honoraria from EchoNous.
Funding: None declared.
Data availability
No new data were generated or analysed in support of this research.
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