Can J Anesth/J Can Anesth
https://doi.org/10.1007/s12630-023-02688-9
CASE REPORTS / CASE SERIES
Transesophageal echocardiographic acquisition of the venous
excess ultrasound exam—a case series and technical description
Acquisition par échocardiographie transœsophagienne de
l’évaluation échographique de l’excès veineux : une série de cas et
une description technique
Nathan H. Waldron, MD, MHSc . Govind Pandompatam, MD . Basar Sareyyupoglu, MD .
Hari Kalagara, MBBS, MD
Received: 19 July 2023 / Revised: 10 October 2023 / Accepted: 11 October 2023
Ó The Author(s) 2024
Abstract Clinical features We describe techniques to acquire and
Purpose Obtaining an objective, reproducible, and interpret a comprehensive TEE-supported VexUS exam,
accurate assessment of volume status is one of the more which may be used to optimize the perioperative care of
difficult tasks in the perioperative arena. Since its advent in cardiac surgical patients.
2020, the Venous Excess Ultrasound (VExUS) score has Conclusion Given the risks of fluid overload in critically ill
gained popularity in the minimally invasive assessment of cardiac surgery patients, TEE-supported VExUS examination
venous congestion. The VExUS exam has been well may be a way to reduce morbidity in this population.
described as an additional series of images (hepatic vein,
portal vein, and intrarenal vein) obtained with a phased- Résumé
array probe during a transthoracic echocardiogram. Objectif L’obtention d’une e´valuation objective,
Nevertheless, there are no descriptions of comprehensive reproductible et pre´cise du statut vole´mique est l’une des
VExUS exams performed using transesophageal tâches les plus difficiles dans l’are`ne périope´ratoire. Depuis
echocardiography (TEE)—a modality that is routinely son introduction en 2020, le score VExUS (pour Venous
employed in patients undergoing cardiac surgery. Excess Ultrasound, soit e´chographie de l’excès veineux) a
gagne´en popularite´dans l’évaluation minimalement invasive
Supplementary Information The online version contains de la congestion veineuse. L’examen e´chographique VExUS a
supplementary material available at https://doi.org/10.1007/s12630- e´te´ bien décrit en tant que série supple´mentaire d’images
023-02688-9.
(veine hépatique, veine porte et veine intrarénale) obtenues à
N. H. Waldron, MD, MHSc (&) l’aide d’une sonde type « phased-array » lors d’un
Department of Anesthesiology and Perioperative Pain Medicine, e´chocardiogramme transthoracique. Néanmoins, il n’existe
Mayo Clinic, Jacksonville, FL, USA aucune description d’examens VExUS complets réalisés à
Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, l’aide d’une sonde d’ETO (échocardiographie
Jacksonville, FL 32224, USA transœsophagienne), une modalite´ couramment utilise´e chez
e-mail: les patientes béne´ficiant d’une chirurgie cardiaque.
Caractéristiques cliniques Nous de´crivons des techniques
G. Pandompatam, MD permettant d’acque´rir et d’interpre´ter un examen VexUS
Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road,
Jacksonville, FL 32224, USA complet par ETO, qui peut eˆtre utilise´pour optimiser les soins
périope´ratoires de la patiente`le en chirurgie cardiaque.
B. Sareyyupoglu, MD Conclusion Compte tenu des risques de surcharge
Department of Cardiovascular Surgery, Mayo Clinic,
Jacksonville, FL, USA
hydrique chez la patiente`le gravement malade en
chirurgie cardiaque, l’examen VExUS base´ sur l’ETO
H. Kalagara, MBBS, MD peut eˆtre un moyen de re´duire la morbidite´ dans cette
Department of Anesthesiology and Perioperative Pain Medicine,
population.
Mayo Clinic, Jacksonville, FL, USA
123
, N. H. Waldron et al.
Keywords cardiac surgery fluid overload View 1: Inferior vena cava long- and short-axis
transesophageal echocardiography
Venous Excess Ultrasound Exam (VExUS) We first obtained this view to determine whether further
VExUS imaging was warranted, as an inferior vena cava
(IVC) diameter \ 2 cm is thought to represent the absence
Description of technique of venous congestion (VExUS grade 0). Of note, positive
pressure ventilation generally increases IVC diameter,4 so
The Venous Excess Ultrasound (VExUS) exam was TEE-guided IVC measurements performed during the
originally described in 20201 as a minimally invasive VExUS exam must be interpreted with caution. From the
assessment of venous congestion using an additional series midesophageal window, the probe was mechanically
of images (hepatic vein, portal vein, and intrarenal vein) rotated clockwise to focus on the right atrium and then
obtained with a phased-array probe during transthoracic advanced until the inferior cavoatrial junction, IVC, and
echocardiography.2 Because fluid overload has been confluence of the hepatic veins were visualized.
associated with suboptimal outcomes in cardiac surgical Alternatively, the IVC can be visualized from the
patients3 and the vast majority of cardiac surgical patients transgastric window by flexing the probe and rotating
receive a comprehensive perioperative transesophageal clockwise until the inferior cavoatrial junction is seen. We
echocardiogram (TEE), we aimed to describe the prefer to use multiplanar imaging to obtain orthogonal
techniques and interpretation of a TEE-supported VExUS views of the intrahepatic cava approximately 2 cm from the
exam. A simplified VExUS algorithm is provided in Fig. 1. confluence of the hepatic veins as previously described,1
Patient consent was obtained for both the acquisition and use M-mode to estimate IVC diameter. If multiplanar
and publication of images. Three patients with differing imaging is unavailable, advancing the omniplane to 50–80°
levels of venous congestion were included in this case typically displays the IVC in long-axis. In the attached
series. All images were obtained during comprehensive images (Figs 2 and 3), the IVC measures well over 2 cm,
transesophageal echocardiography (TEE) exams performed indicating a need for further imaging of the hepatic, portal,
as part of cardiothoracic surgical cases. Of note, the views and/or renal veins. In contrast, an IVC diameter \ 2 cm
were obtained with standard TEE windows (distal would represent a VExUS score of 0, and the exam could
esophageal and transgastric) and only slight additional be stopped in that case.
probe manipulations, so minimal additional risk was
incurred. In patients with contraindications to or View 2: Hepatic vein imaging
difficulty with transgastric probe advancement, a TEE-
guided VExUS exam should not be performed. Imagers may need to slightly advance the probe to image
the hepatic veins, taking care to ensure favourable
Fig. 1 Simplified VExUS
algorithm that can be applied to
either transthoracic or
transesophageal
echocardiography
HVD = hepatic venous Doppler;
IVC = inferior vena cava;
PVD = portal venous Doppler;
RVD = renal venous Doppler;
VExUS = Venous Excess
Ultrasound
123
https://doi.org/10.1007/s12630-023-02688-9
CASE REPORTS / CASE SERIES
Transesophageal echocardiographic acquisition of the venous
excess ultrasound exam—a case series and technical description
Acquisition par échocardiographie transœsophagienne de
l’évaluation échographique de l’excès veineux : une série de cas et
une description technique
Nathan H. Waldron, MD, MHSc . Govind Pandompatam, MD . Basar Sareyyupoglu, MD .
Hari Kalagara, MBBS, MD
Received: 19 July 2023 / Revised: 10 October 2023 / Accepted: 11 October 2023
Ó The Author(s) 2024
Abstract Clinical features We describe techniques to acquire and
Purpose Obtaining an objective, reproducible, and interpret a comprehensive TEE-supported VexUS exam,
accurate assessment of volume status is one of the more which may be used to optimize the perioperative care of
difficult tasks in the perioperative arena. Since its advent in cardiac surgical patients.
2020, the Venous Excess Ultrasound (VExUS) score has Conclusion Given the risks of fluid overload in critically ill
gained popularity in the minimally invasive assessment of cardiac surgery patients, TEE-supported VExUS examination
venous congestion. The VExUS exam has been well may be a way to reduce morbidity in this population.
described as an additional series of images (hepatic vein,
portal vein, and intrarenal vein) obtained with a phased- Résumé
array probe during a transthoracic echocardiogram. Objectif L’obtention d’une e´valuation objective,
Nevertheless, there are no descriptions of comprehensive reproductible et pre´cise du statut vole´mique est l’une des
VExUS exams performed using transesophageal tâches les plus difficiles dans l’are`ne périope´ratoire. Depuis
echocardiography (TEE)—a modality that is routinely son introduction en 2020, le score VExUS (pour Venous
employed in patients undergoing cardiac surgery. Excess Ultrasound, soit e´chographie de l’excès veineux) a
gagne´en popularite´dans l’évaluation minimalement invasive
Supplementary Information The online version contains de la congestion veineuse. L’examen e´chographique VExUS a
supplementary material available at https://doi.org/10.1007/s12630- e´te´ bien décrit en tant que série supple´mentaire d’images
023-02688-9.
(veine hépatique, veine porte et veine intrarénale) obtenues à
N. H. Waldron, MD, MHSc (&) l’aide d’une sonde type « phased-array » lors d’un
Department of Anesthesiology and Perioperative Pain Medicine, e´chocardiogramme transthoracique. Néanmoins, il n’existe
Mayo Clinic, Jacksonville, FL, USA aucune description d’examens VExUS complets réalisés à
Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road, l’aide d’une sonde d’ETO (échocardiographie
Jacksonville, FL 32224, USA transœsophagienne), une modalite´ couramment utilise´e chez
e-mail: les patientes béne´ficiant d’une chirurgie cardiaque.
Caractéristiques cliniques Nous de´crivons des techniques
G. Pandompatam, MD permettant d’acque´rir et d’interpre´ter un examen VexUS
Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road,
Jacksonville, FL 32224, USA complet par ETO, qui peut eˆtre utilise´pour optimiser les soins
périope´ratoires de la patiente`le en chirurgie cardiaque.
B. Sareyyupoglu, MD Conclusion Compte tenu des risques de surcharge
Department of Cardiovascular Surgery, Mayo Clinic,
Jacksonville, FL, USA
hydrique chez la patiente`le gravement malade en
chirurgie cardiaque, l’examen VExUS base´ sur l’ETO
H. Kalagara, MBBS, MD peut eˆtre un moyen de re´duire la morbidite´ dans cette
Department of Anesthesiology and Perioperative Pain Medicine,
population.
Mayo Clinic, Jacksonville, FL, USA
123
, N. H. Waldron et al.
Keywords cardiac surgery fluid overload View 1: Inferior vena cava long- and short-axis
transesophageal echocardiography
Venous Excess Ultrasound Exam (VExUS) We first obtained this view to determine whether further
VExUS imaging was warranted, as an inferior vena cava
(IVC) diameter \ 2 cm is thought to represent the absence
Description of technique of venous congestion (VExUS grade 0). Of note, positive
pressure ventilation generally increases IVC diameter,4 so
The Venous Excess Ultrasound (VExUS) exam was TEE-guided IVC measurements performed during the
originally described in 20201 as a minimally invasive VExUS exam must be interpreted with caution. From the
assessment of venous congestion using an additional series midesophageal window, the probe was mechanically
of images (hepatic vein, portal vein, and intrarenal vein) rotated clockwise to focus on the right atrium and then
obtained with a phased-array probe during transthoracic advanced until the inferior cavoatrial junction, IVC, and
echocardiography.2 Because fluid overload has been confluence of the hepatic veins were visualized.
associated with suboptimal outcomes in cardiac surgical Alternatively, the IVC can be visualized from the
patients3 and the vast majority of cardiac surgical patients transgastric window by flexing the probe and rotating
receive a comprehensive perioperative transesophageal clockwise until the inferior cavoatrial junction is seen. We
echocardiogram (TEE), we aimed to describe the prefer to use multiplanar imaging to obtain orthogonal
techniques and interpretation of a TEE-supported VExUS views of the intrahepatic cava approximately 2 cm from the
exam. A simplified VExUS algorithm is provided in Fig. 1. confluence of the hepatic veins as previously described,1
Patient consent was obtained for both the acquisition and use M-mode to estimate IVC diameter. If multiplanar
and publication of images. Three patients with differing imaging is unavailable, advancing the omniplane to 50–80°
levels of venous congestion were included in this case typically displays the IVC in long-axis. In the attached
series. All images were obtained during comprehensive images (Figs 2 and 3), the IVC measures well over 2 cm,
transesophageal echocardiography (TEE) exams performed indicating a need for further imaging of the hepatic, portal,
as part of cardiothoracic surgical cases. Of note, the views and/or renal veins. In contrast, an IVC diameter \ 2 cm
were obtained with standard TEE windows (distal would represent a VExUS score of 0, and the exam could
esophageal and transgastric) and only slight additional be stopped in that case.
probe manipulations, so minimal additional risk was
incurred. In patients with contraindications to or View 2: Hepatic vein imaging
difficulty with transgastric probe advancement, a TEE-
guided VExUS exam should not be performed. Imagers may need to slightly advance the probe to image
the hepatic veins, taking care to ensure favourable
Fig. 1 Simplified VExUS
algorithm that can be applied to
either transthoracic or
transesophageal
echocardiography
HVD = hepatic venous Doppler;
IVC = inferior vena cava;
PVD = portal venous Doppler;
RVD = renal venous Doppler;
VExUS = Venous Excess
Ultrasound
123
