Venous Excess Ultrasound and Adverse Renal and Clinical Outcomes in Acute Heart Failure and Critical Illness: A Systematic Review and Meta-analysis

Abstract

Background: Venous Excess Ultrasound (VExUS) is increasingly used as a bedside tool to assess systemic venous congestion, but its prognostic value for renal deterioration and short-term clinical outcomes in acute heart failure and critical illness remains uncertain. We conducted a systematic review and meta-analysis to evaluate the association between VExUS or related venous congestion ultrasound constructs and adverse renal and mortality outcomes. Methods: This systematic review and meta-analysis was prospectively registered in PROSPERO (CRD420261366890). PubMed, Embase, and other major databases were systematically searched from database inception to 2020 for prospective observational studies evaluating formal VExUS or related venous Doppler-based congestion assessments in acute heart failure or critical care settings. The primary quantitative synthesis was restricted to studies using formal VExUS and reporting comparable AKI/WRF-type renal outcomes. Risk of bias was assessed using the Quality in Prognosis Studies tool. Results: Thirteen prospective observational studies involving 1,210 participants were included. Study populations, ultrasound exposure definitions, scan timing, and outcome definitions were heterogeneous. In the primary renal meta-analysis, higher formal VExUS burden was associated with directionally higher odds of adverse renal outcomes, although the estimate was imprecise and heterogeneity was substantial (5 studies; pooled OR 2.85, 95% CI 0.60–13.43; I² = 79.0%). For short-term mortality, formal VExUS data from 3 studies showed a similarly adverse but highly imprecise association (pooled OR 2.64, 95% CI 0.02–310.14; I² = 87.8%). Non-poolable outcomes, including MAKE30 and organ dysfunction, generally showed worse outcomes among patients with greater venous congestion burden. Conclusions: Higher VExUS burden may be associated with adverse renal and short-term clinical outcomes in acute heart failure and critical illness. However, current evidence remains limited by observational study design, small pooled datasets, substantial heterogeneity, and imprecision. Standardized VExUS acquisition protocols, exposure thresholds, and outcome definitions are needed to clarify its prognostic role and potential clinical utility.