A brief dissertation on the impact of right atrial pressure on preload vs organ venous congestion 🧵
You are asked to evaluate 2 patients with venous congestion and kidney injury.
Which patient is more congested?
Which of them can tolerate more aggressive decongestion? 1/7
You are asked to evaluate 2 patients with venous congestion and kidney injury.
Which patient is more congested?
Which of them can tolerate more aggressive decongestion? 1/7
¿Which patient is has a worst degree of organ congestion? 2/7
Which of them can better tolerate more aggressive decongestion? 3/7
I would argue congestion is pretty similar in both cases: Portal Vein has reverse flow and RVSI (Renal Venous Stasis Index) is > 0.5
Strictly speaking pt B has worse congestion, more flow reversal and higher RVSI
The second question requires analysis of the CVP waveform
4/7
Strictly speaking pt B has worse congestion, more flow reversal and higher RVSI
The second question requires analysis of the CVP waveform
4/7
Patient A has a normal RA filling pattern
Patient B has severe TR with HV "S" wave reversal
While both patients have a large retrograde flow towards the organs, it is very possible patient B has a lower absolute preload value (because of the CVP morphology in severe TR)!
6/7
Patient B has severe TR with HV "S" wave reversal
While both patients have a large retrograde flow towards the organs, it is very possible patient B has a lower absolute preload value (because of the CVP morphology in severe TR)!
6/7
Hence, it is my opinion that patient A is more likely to tolerate aggressive decongestion!
In these particular examples this was actually the case!
Would love to hear your thoughts @Thind888 @msiuba @ThinkingCC @khaycock2 @MDBeni @katiewiskar @load_dependent @curromir @NephroP
In these particular examples this was actually the case!
Would love to hear your thoughts @Thind888 @msiuba @ThinkingCC @khaycock2 @MDBeni @katiewiskar @load_dependent @curromir @NephroP
For clearness: I don’t pretend to know what the actual preload is in each case. The point is that in order to normalize PV/IRV it would take a greater decrease in preload for pt B since the pressure wave traveling backwards (CV fusion) is further away from that filling the RV
Hence, aiming to normalize PV/IRV Doppler alterations would be better tolerated for patient A. In patient B, flow alterations might be imposible to completely normalize as is our experience with PAH and severe TR!
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