Lower Extremity Venous Pulsatility Warrants Screening for Right Heart Dysfunction

Document Type

Conference Proceeding

Publication Date

3-1-2025

Publication Title

J Vasc Surg Venous Lymphat Disord

Keywords

adult, aged, cohort analysis, conference abstract, deep vein thrombosis, diagnosis, diagnostic test accuracy study, echocardiograph, echocardiography, female, heart atrium contraction, heart cycle, heart disease, heart failure, heart right atrium pressure, heart right ventricle failure, heart ventricle function, human, lower limb, lung artery pressure, major clinical study, male, predictive value, pulsatility index, retrospective study, tricuspid valve regurgitation, vein blood flow, waveform

Abstract

Objectives: There is considerable disagreement among clinicians regarding the interpretation of pulsatile venous waveforms, ranging from normal physiologic variation to potential indicators of elevated right atrial pressure (RAP) or severe tricuspid regurgitation. This study aims to evaluate the diagnostic performance of pulsatile venous flow in detecting elevated RAP, elevated pulmonary artery pressure (PAP), and right ventricular dysfunction. Methods: All patients who underwent lower extremity venous duplex ultrasound (VDUS) and concurrent cardiac echocardiogram within 14 days between January 2020 and February 2024 at a quaternary medical center were reviewed. Patients with evidence of deep venous thrombosis and those with unilateral pulsatile venous flow were excluded. Pulsatile venous flow was defined as retrograde flow during atrial systole of the cardiac cycle. An elevated RAP was defined as a RAP ≥8 mmHg, and an elevated PAP was defined as a PAP >30 mmHg. Simplified echocardiographic pulmonary artery pulsatility index (ePAPI) was calculated as the ratio of the tricuspid regurgitation gradient to the RAP, and right ventricular dysfunction was defined as a simplified ePAPI ≤3.1. Correlations between pulsatile venous flow and each of RAP, PAP, and right ventricular dysfunction were assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: A total of 5223 patients were included in the study, of which 868 patients (15%) had pulsatile venous flow, 3643 (63%) had an elevated RAP, and 4072 (70%) had an elevated PAP. The assessment of pulsatile venous flow in detecting elevated RAP and PAP demonstrated a sensitivity of 20% and 19% respectively, and specificity of 90% and 91% respectively. The PPV of pulsatile venous flow in confirming elevated RAP and PAP were 77% (671/868) and 81% (706/868) respectively, suggesting that there is a 77% and 81% likelihood that patients with pulsatile venous flow had an elevated RAP and PAP respectively. Nonetheless, the NPV was 40% (1742/4355) and 33% (1416/4355), respectively, indicating that only 40% and 33% of patients did not have elevated RAP and PAP despite normal venous flow. Normal venous flow demonstrated high accuracy in ruling out right ventricular dysfunction with an NPV of 86%. Conclusions: A finding of pulsative venous flow on VDUS exhibits a high PPV for elevated RAP and PAP, warranting screening for right heart failure in patients presenting with lower extremity venous pulsatility. Nevertheless, this finding exhibits a moderate NPV, thus limiting its effectiveness as a standalone diagnostic tool for ruling out right heart dysfunction. Clinicians should exercise caution in interpreting negative results, as they may overlook significant cases of elevated RAP and PAP and provide potential false reassurance in these cases.

Volume

13

Issue

2

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