The ECG shows no P waves so, no
possibility of atrial fibrillation, and AV dissociation cannot be commented
upon. Hence, the most likely ECG diagnosis
is accelerated junctional rhythm.
The echocardiographic
findings are most consistent with severe systemic venous congestion (VExUS
grade 3). VExUS integrates abnormalities in the IVC and
systemic venous Doppler waveforms to assess the severity of
venous congestion and its potential impact on organ perfusion.
The
diagnosis of VExUS grade 3 is supported by:
- Severely dilated IVC with reduced
respiratory variation, indicating elevated right atrial pressure.
- Severely abnormal hepatic vein Doppler,
with reversal of flow during systole. This is a particularly important
marker of significant venous congestion.
- Abnormal portal vein Doppler,
demonstrating marked pulsatility (>50%), reflecting transmission of
elevated right-sided pressures into the portal circulation.
- Severely abnormal intrarenal venous
Doppler, with a discontinuous/biphasic or monophasic venous flow pattern,
indicating significant renal venous congestion.
Therefore, the correct answer is option ācā.
Why is this clinically important?
- Severe venous congestion can increase renal
venous pressure and interstitial pressure, impairing the renal perfusion
gradient and contributing to postoperative acute kidney injury and oliguria. It
may also reflect significant right-sided cardiac loading and impaired forward
flow.
- Therefore, in this patient with postoperative
hemodynamic deterioration, the echocardiographic findings provide strong
evidence of severe systemic venous congestion (VExUS grade 3).
- The line of management would be to start on AV
sequential pacing and diuresis.
References:
- Assavapokee T, Rola P, Assavapokee N, Koratala
A. Decoding VExUS: a practical guide for excelling in point-of-care ultrasound
assessment of venous congestion. Ultrasound J 2024;16:48.
- Guinot PG. VExUS score: optimizing its use in
perioperative and critical care management. Crit Care 2025;29:472.