Abstract
<jats:p>Acute decompensated heart failure (HF) represents one of the leading causes of hospitalization worldwide, carrying significant morbidity and mortality. Its pathophysiology encompasses impaired cardiac pump function, elevated systemic venous pressure, diuretic unresponsiveness, and acute kidney injury (AKI). Accurate bedside assessment of congestion severity remains challenging, as clinical signs are inconsistent and invasive hemodynamic monitoring is not routinely feasible. The venous excess ultrasound (VExUS) score offers a non-invasive, repeatable bedside tool for grading systemic venous congestion. It integrates inferior vena cava (IVC) diameter measurements with pulsed-wave Doppler interrogation of the hepatic, portal, and inter-lobar renal veins, producing a four-tiered grading system (grades 0–3) that reflects the extent of multi-organ venous overload. This scoring system has been validated across diverse clinical settings, including type 1 cardio-renal syndrome. Accumulating evidence demonstrates that higher VExUS grades at admission independently predict AKI, reduced diuretic efficacy, progressive renal deterioration, and increased short-term mortality in hospitalized HF patients. Serial VExUS assessments during the hospital course provide dynamic, real-time information on decongestion trajectory, enabling timely adjustment of diuretic therapy and early identification of renal complications. Data from randomized trials further suggest that VExUS-guided management improves rates of complete decongestion compared with conventional approaches. Certain conditions — including tricuspid regurgitation, right-sided HF, positive-pressure ventilation, and hepatic fibrosis — may limit the score’s accuracy. Despite these limitations, the VExUS score represents a clinically valuable and pragmatic instrument for guiding cardio-renal management in decompensated HF.</jats:p>