KEY POINTS:Point-of-care ultrasound could provide important information to guide fluid administration in AKI. This study demonstrates the feasibility assessing fluid tolerance through lung and venous ultrasound and implementing it in a trial. Point-of-care ultrasound influenced management in half of patients and lead to higher rate of early diuretic use without negatively affecting kidney function. BACKGROUND:Indiscriminate fluid administration in AKI can be harmful, and point-of-care ultrasound (POCUS) could be used to assess for fluid tolerance. The objective of pilot study was to determine the feasibility of a randomized trial comparing a fluid management strategy, including POCUS, with usual care. METHODS:This is a single-center, open-label, pilot randomized controlled trial that recruited noncritically ill patients with AKI for whom fluid administration had begun or was considered. The intervention consisted in the transmission to the nephrology team of a POCUS report on fluid tolerance (assessment of pulmonary B-lines and systemic venous congestion with the venous excess ultrasound score). The control was usual care without POCUS. The primary outcome was feasibility, defined as protocol adherence. RESULTS:Eighty patients underwent randomization, 40 were randomized in the POCUS group and 40 in the usual care group, but one withdrew consent before initiating trial procedures. Protocol adherence was achieved in all patients. In the intervention arm, 50% of initial ultrasound reports led to a change in clinical conduct, and the provided information was perceived as useful by clinicians (median 4.5/5 [interquartile range, 4.0-5.0]). The intervention led to a higher use of diuretics during the first day after randomization (40% versus 15%, P = 0.01), but did not result in difference in cumulative fluid balance or diuretic use at 5 days, progression to higher stages of AKI, or composite outcome of death and escalation of care. CONCLUSIONS:This pilot trial demonstrate the feasibility of a randomized trial investigating the clinical effect of providing a POCUS fluid tolerance evaluation in AKI. Its effect on clinical management and perceived usefulness support the rationale for future, larger-scale studies.Clinical Trial registry name and registration number: NCT06411080 .

Introduction: Predicting tolerance to fluid removal is particularly challenging in hospitalized, acutely ill patients. This study evaluated the association between the Venous Excess Ultrasound (VExUS) and IDHE in hospitalized patients. Methods: This single-center prospective cohort included hospitalized between 2022 and 2024 receiving hemodialysis. Ultrasound of the inferior vena cava (IVC), hepatic, portal, and femoral veins was performed. Patients were classified into four VExUS grades (0 to 3) based on IVC dimensions and venous Doppler waveforms. Follow-up at 3 months was conducted to evaluate outcomes across the different groups. Results: The cohort consisted of 93 patients. VExUS grading showed grade 0 in 52 patients (55.9%), grade 1 in 22 patients (23.7%), grade 2 in 11 patients (11.8%), and grade 3 in 8 patients (8.6%). The incidence of IDHE was tended to be higher in VExUS grade 0 (40.4%) and VExUS grade 3 (50.0%) patients compared with VExUS grade 1 (18.2%) or 2 (18.2%) (p = 0.145). The cumulative duration of hypotension (sBP <90 mm Hg) differed between VExUS groups (p = 0.03), with VExUS grade 3 patients experiencing longer median duration of hypotension compared to participants with a VExUS grade 1 (16.4 [0; 47.5] vs. 0 [0; 0] min, p = 0.04). Conclusion: Our findings showed a trend toward more frequent IDHE in both VExUS grade 0 and grade 3, with grade 3 patients experiencing a significantly longer cumulative duration of hypotension. High VExUS scores may identify patients at increased risk of hypotension due to impaired hemodynamic adaptability.

Principles of Ultrasound. Basic Principles of Doppler Ultrasound. Transducers Normal Anatomy and Flow. Quantitative Echocardiography. Imaging Artifacts and Pitfalls.Equipment, Complications, Infection Control, and Safety. Segmental Ventricular Function and Ischema. Global Ventricular Function and Hemodynamics. Cardiomyopathy. Pericardium. Aorta. Echocardiography During Cardiac Surgery. Perioperative Role of TEE in Mechanical Circulatory Assistance. Native Aortic Valve.

Right ventricular (RV) injury (including RV dilatation/dysfunction/limitation/failure) and pulmonary vascular dysfunction are common in patients with acute respiratory distress syndrome (ARDS). Despite increasing recognition, RV injury is associated with increased mortality in patients with ARDS, and implementation of multimodal monitoring and timely RV-targeted interventions may therefore confer outcome benefit. The aim of this narrative review is to explore the clinical applications of diagnostic modalities for the RV and pulmonary circulation in invasively ventilated patients with ARDS, including the complementary roles of invasive hemodynamics, echocardiography, and pulmonary monitoring. We discuss the physiologic basis and utility of RV and pulmonary monitoring to guide the bedside intensivist in personalizing therapies aimed at protecting the RV. Building on previous work that focused on the principles and terminology of abnormal RV biomechanics in critical illness, this review is centered on monitoring of RV pathophysiology in ARDS and implications for bedside management.

Background:Lung ultrasound (LUS) is increasingly recognised as an essential diagnostic and monitoring tool in acute and critical care. As its use grows, understanding how LUS education is designed, delivered, and evaluated for practicing healthcare professionals has become essential. Objective:To map the evidence on educational interventions for LUS training, focusing on study characteristics, instructional strategies, and learning outcomes. Methods:This scoping review followed the Joanna Briggs Institute methodology and PRISMA-ScR reporting guidelines. It identified and charted studies on LUS training for practicing healthcare professionals. Data extraction covered study characteristics, learner profiles, instructional strategies, instructor credentials, training duration and setting, and learning outcomes, categorised using the New World Kirkpatrick Model. Results:Thirty eight studies involving physicians, paramedics, respiratory therapists, physiotherapists, and nurses met inclusion criteria. Most interventions combined didactic teaching with hands-on practice, including supervised scanning and simulation. Training was typically brief (median duration = 3.5 h). Outcomes focused mainly on learning (Level 2: 86.8%) and less often on behaviour (Level 3: 47.4%). Considerable variation in educational designs and outcome measures limited cross-study comparisons, and few studies assessed long-term retention or clinical impact. Conclusion:Current LUS training uses multimodal approaches that integrate theory with supervised practice. However, programs and assessments remain heterogeneous and rarely theory-informed. Future research should strengthen pedagogical foundations, align evaluation with competency frameworks, and examine learning sustainability, interprofessional training, and patient-centred outcomes to support effective and scalable LUS education.

Artificial intelligence (AI) embedded in point-of-care ultrasound (POCUS) could reduce operator dependence in left ventricular ejection fraction (LVEF) assessment and accelerate bedside decision making by non-cardiologists and non-radiologists. Prospective comparative studies evaluating real-time AI-assisted POCUS for LVEF across point-of-care settings were systematically reviewed. The PubMed/MEDLINE, Embase, and Cochrane databases were searched from inception to June 11, 2025. The authors included prospective analytical observational studies in intensive care unit (ICU), emergency department, perioperative, ward, or home settings that used AI during image acquisition and/or interpretation to estimate LVEF in real time against a reference standard. Risk of bias was appraised using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Because of heterogeneity, the findings were narratively synthesized. Twelve studies met the inclusion criteria across ICU, emergency department, perioperative, ward, and community settings. For continuous outcomes, agreement (r) between AI-derived and reference LVEF ranged from 0.56 to 0.92 and intraclass correlation coefficients ranged from 0.84 to 0.94. Bland-Altman analyses demonstrated broad limits of agreement, from approximately -31.8% to +20.0%, often indicating a tendency for AI to underestimate LVEF compared with reference measures. For categorical classification at a 50% threshold, sensitivities ranged from 70% to 93%; specificities, from 89% to 100%; and areas under the receiver operating characteristic curves, from 0.85 to 0.98. Weighted κ values ranged from 0.49 to 0.83. No study achieved a low risk of bias across all QUADAS-2 domains. AI-assisted POCUS can approximate reference LVEF and reasonably classify reduced LVEF at the bedside, supporting its use as a screening and triage tool in settings in which comprehensive echocardiography is not immediately available. Future studies should adopt intention-to-diagnose designs, standardize the Simpson biplane reference, minimize test delay, report calibration and failure rates, and incorporate image quality feedback.

BACKGROUND: The assessment of the right heart (RH) plays a central role in the diagnosis and management of cardiovascular and pulmonary diseases. Although current guidelines have improved standardization, there is anecdotal evidence suggesting that there is significant variability in clinical practice regarding acquisition and reporting persist. OBJECTIVES: This international survey evaluated the extent of variability in echocardiographic assessment of the RH. A simple method for the standardization of RH measurements is proposed. METHODS: The international anonymous survey consisted of 68 questions with a primary focus on routine methods and measurements of RH echocardiography by transthoracic (TTE) and transesophageal (TEE) modalities. The questions were developed using a standardization framework, focused on six key areas: views and settings, phase, orientation, interface, timing and selection, as well as scaling and indexing (V-POINTS). RESULTS: The survey was available from November 2024 to February 2025. A total of 588 international respondents from various disciplines and professions responded. The majority of respondents had certification in echocardiography (74%), 34% reported 10 to 20 years of experience, 22% reported more than 20 years of experience. The 4-chamber (80%) and right ventricular (RV) focused (67%) views were most commonly used in TTE. The functional parameters included tricuspid annular plane systolic excursion (TAPSE) (80%), visual assessment (66%), RV S’ (50%), and fractional area change (FAC) (42%). RV strain and 3D metrics were less frequently used. Using TEE the mid-esophageal 4-chamber view was most commonly used (80%), RV function was mostly assessed visually, and quantification playing a secondary role (TAPSE 44% and RVFAC 34%). There was considerable variability in the definition of cardiac phases across both modalities. RV dimensions and areas were measured at the compacted region by 58% of the respondents. Scaling and indexing were not routinely used in practice. CONCLUSIONS: The survey identified significant variability in the practice of RH echocardiography. We propose a simple system (V-POINTS) which may improve standardization of image acquisition and corresponding measurements.

Accurate hemodynamic monitoring is essential for personalized care in surgical and intensive care unit (ICU) settings, and radial artery catheters are the gold standard. Nevertheless, central-to-peripheral arterial blood pressure gradients (CPAPGs) have been reported in up to 77 CRD42024561474 ); first submitted 10 July 2024.

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are now increasingly used for glycemic control in type 2 diabetes mellitus as well as for weight loss. Their effect on gastric emptying may increase the risk of aspiration in the perioperative setting; unfortunately, the optimal schedule of perioperative holding of GLP-1 RA is unclear. We conducted a cross-sectional prospective study at two university affiliated hospitals in Montreal, Canada, comparing the preoperative prevalence of increased residual gastric content (RGC) on gastric ultrasound (GUS) between two groups of fasted adults scheduled for elective surgery: (i) an exposure group of patients receiving a weekly injectable GLP-1 RA and discontinued for ≥ 7 days before surgery, regardless of indication; and (ii) a control group of patients not receiving any GLP-1 RA, preferentially with type 2 diabetes or with a body mass index ≥ 25 kg/m². The primary outcome was increased RGC, defined as the presence of solid content, thick liquid, or > 1.5 mL/kg of clear liquid. Confounding was addressed using overlap-weighting propensity-score adjustment. 93 patients were included. The unadjusted prevalence of increased RGC was 24

Doppler ultrasound assessment of common femoral vein (CFV) flow could represent a simple, fast, and noninvasive technique to identify right ventricular dysfunction and venous congestion in patients undergoing cardiac surgery. Our primary objective was to determine the prevalence of abnormal CFV flow pulsatility before cardiac surgery. Secondary objectives included investigating its association with postoperative outcomes. We conducted a single-centre prospective cohort study and recruited adult patients undergoing cardiac surgery with cardiopulmonary bypass. We performed pulsed-wave Doppler ultrasound assessments of CFV flow at four timepoints: before surgery, after induction of anesthesia, immediately after surgery, and on postoperative day 1. When the Doppler profile showed cardiophasic variations in velocities, abnormal pulsatility was defined as a CFV pulsatility fraction ≥ 100 NCT05038267 ); first submitted 28 August 2021.

Background: Right ventricular (RV) function is a key determinant of outcomes in lung transplantation, particularly in patients with pre-existing pulmonary hypertension. The RV is uniquely sensitive to perioperative hemodynamic stressors, including ischemia-reperfusion injury, abrupt afterload changes, and allograft implantation. Purpose: This review aims to summarize the perioperative echocardiographic assessment of RV function in lung transplantation, emphasizing the role of transesophageal echocardiography (TEE) in evaluating RV performance and guiding intraoperative management. Methods: A comprehensive synthesis of recent literature was performed, focusing on echocardiographic parameters relevant to RV evaluation during the preoperative, intraoperative, and postoperative phases of lung transplantation. Both conventional and advanced imaging modalities were reviewed. Discussion: TEE provides real-time insights into RV adaptation and dysfunction. Key parameters include fractional area change, tricuspid annular plane systolic excursion (TAPSE), tricuspid annular velocity (S’), and speckle-tracking–derived strain. Three-dimensional echocardiography enhances volumetric and geometric assessment, while venous congestion indices such as the Venous Excess Ultrasound (VExUS) score offer indirect hemodynamic evaluation. Intraoperatively, dynamic monitoring supports optimization of preload, afterload, and inotrope therapy. Postoperative complications—such as RV outflow tract obstruction and pulmonary vascular anastomotic dysfunction—require prompt recognition. Persistent RV dysfunction despite afterload reduction may reflect intrinsic myocardial disease. Conclusion: Comprehensive echocardiographic evaluation throughout all perioperative phases is essential for optimizing RV performance and improving outcomes in lung transplantation. Future studies should aim to standardize RV assessment protocols and validate multimodal imaging approaches for perioperative clinical decision-making.

The VExUS score is meant to alert the clinician to an uncoupling at the right ventricular (RV)-pulmonary artery (PA) interface. Bedside ultrasonography and determination of the etiology of an abnormal VExUS score is the first step.

Heart failure (HF) leads to venous congestion (VC), leading to organ dysfunction. Traditional VC assessments include pulmonary artery catheterization and IVC ultrasound. Newer tools like venous excess ultrasound (VExUS) and femoral venous doppler (FVD) quantify VC severity. We aimed to compare FVD with VExUS score to predict organ dysfunction and its progression in acute HF patients. We conducted a 6-month prospective study in a 36-bed Cardiac ICU, enrolling 111 adults with acute decompensated HF. We evaluated FVD and VExUS to predict organ dysfunction and its progression. Key parameters were recorded on ICU admission and Day 3. We followed up patients at 90-days using the MAKE-90 criteria. Sensitivity, specificity, and predictive values of FVD and VExUS were calculated and compared using McNemar’s test. VC was higher in the organ dysfunction group, with higher VExUS scores (55 https://www.ctri.nic.in/ ), Trial No—CTRI/2023/10/058186 on 3/10/2023.

Background During cardiac surgery, right ventricular outflow tract obstruction (RVOTO) is defined as an instantaneous pressure difference ≥6 mmHg between right ventricular systolic pressure (RVSP) and pulmonary artery systolic pressure (PASP), for ≥5 minutes. Risk factors for RVOTO remain poorly understood. This cohort study is designed to evaluate the incidence, characteristics and outcomes of the patients who experienced RVOTO. Methods Instantaneous pressure difference between RVSP and PASP was measured using a pulmonary artery catheter with a right ventricular port during cardiac surgery from a retrospective (n=295) and a prospective (n=105) cohort. Results From the retrospective and prospective cohort, incidence of RVOTO was 30.2 and 36.2% before cardiopulmonary bypass (CPB) initiation and 43.7 and 47.6% after CPB separation. Before CPB initiation, patients with RVOTO had higher cardiac output (4.2±1.5 vs 3.8±1.1L⋅min-1, P=0.033), received more inhaled epoprostenol (79 vs 61%, P=0.005) and inotropes (66 vs 51%, P=0.016) compared to those without RVOTO. After CPB separation, patients with RVOTO had higher heart rate (62±15 vs 58±13 beats⋅min-1, P=0.011), cardiac output (4.1±1.4 vs 3.7±1.1L⋅min-1, P=0.003), CPB duration (90±45 vs 77±30mins, P=0.014), lower fluid balance (758±1123 vs 1063±1089mL, P=0.021) and were more exposed to intratracheal milrinone (12 vs 4%, P=0.015) compared to those without RVOTO. The time with persistent organ dysfunction (TPOD) at 28 days after surgery was similar among patients who had a RVOTO event, before CPB initiation or after CPB separation, compared to those who did not. Conclusion RVOTO is common in cardiac surgery. However, it is not associated with longer TPOD.

Vascular access is a commonly performed procedure to facilitate patient care. This document provides expert consensus from diverse specialists on best practices and techniques for incorporating ultrasound (US) into vascular access procedures. This update replaces the 2011 American Society of Echocardiography guidelines for US-guided vascular cannulation. It includes recommendations for US-guided access to central and peripheral veins and arteries in adult and pediatric patients based on the strength of the scientific evidence present in the literature. The major roles of US during vascular access include (1) precannulation vessel assessment, (2) dynamic US guidance during cannulation, and (3) identification of local complications. This document discusses the general aspects of anatomic and US imaging of vessels, US-guided vascular cannulation techniques, and the identification of local vascular cannulation complications. Proper training should impart the cognitive knowledge and technical skills necessary to perform US-guided cannulation. There is an increasing body of literature indicating that US-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak. A gap remains between the existing evidence and guidelines for the use of US in clinical practice. The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies. (J Am Soc Echocardiogr 2025;38:57-91.)

Pulmonary hypertension is a risk factor for increased morbidity and mortality in cardiac surgery. The use of a combination of inhaled vasodilator agents could have an improved effect on pulmonary vascular resistance in the perioperative cardiac surgery setting without causing the systemic side effect of hypotension observed with intravenous agents. There is currently limited evidence regarding the use of combination therapy for pulmonary hypertension in the context of cardiac surgery. A scoping review was conducted to retrieve relevant literature on the use of a combination of inhaled vasodilator agents in the treatment of pulmonary hypertension and/or right ventricular dysfunction in adults and children undergoing cardiac surgery. The authors searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to April 2025 for relevant articles. They identified 23 studies including 432 patients. The combined inhaled therapies reported in the literature are nitric oxide or milrinone combined with prostacyclin analogues. Of the 23 studies, 18 reported a hemodynamic benefit of the drugs in decreasing pulmonary hypertension and improving right ventricular function. Decreased intraoperative and postoperative vasopressor and/or inotropic use also was observed. Moreover, the impact on clinical outcomes, such as difficulty in weaning from cardiopulmonary bypass and length of intensive care unit stay, showed conflicting results. No study has reported an impact on mortality, length of hospital stay, or other intraoperative or postoperative complications. Combined therapies are promising therapeutic alternatives for the management of pulmonary hypertension and/or right ventricular dysfunction in cardiac surgery, but more studies are required to determine their systemic effects and impact on clinical outcomes.