Venous congestion is increasingly recognized as a significant cause of morbidity and mortality in many highly morbid conditions [1,2,3,4,5,6,7,8], contributing to cardiorenal acute kidney injury (AKI), pulmonary edema, and organ hypoperfusion, among others [9]. For this reason, the ability of providers to rigorously assess venous congestion is critical to the daily management of a wide variety of patients. Unfortunately, evaluation of venous congestion is clinically challenging, and conventional exam techniques are often inadequate [10, 11]. For this reason, clinicians seeking definitive information on a patient’s degree of venous congestion often rely on right heart catheterization (RHC), the clinical gold standard for assessing venous hypertension [12]. However, RHC is an invasive and costly procedure that is not universally available, and is associated with a risk of patient complication as high as 1%, even in high-volume centers [13]. These limitations have led to an ongoing search for a non-invasive, economical, and reliable bedside procedure that can be used to assess a patient’s degree of venous congestion at the bedside [14].

To address this need, the Venous Excess Ultrasound Score (VExUS)—a novel ultrasonographic technique was designed to noninvasively assess venous congestion [15]. The VExUS technique leverages the fact that characteristic Doppler waveforms are associated with different degrees of venous congestion in the peripheral organs, and combines them into a unified assessment of venous circulation, including measurements of the inferior vena cava (IVC), hepatic, portal, and renal veins [15, 16]. The initial VExUS study reported an positive likelihood ratio of 6.37 for the development of cardiorenal acute injury (AKI) [15], and VExUS has been shown to have clinical utility in a variety of settings, including predicting resolution of cardiorenal AKI, and in evaluating volume status in the perioperative, intensive, care, and emergency settings [17, 18]. Importantly, a recent study demonstrated that VExUS grade is closely correlated with right atrial pressure, showing VExUS to have an AUC of 0.99 for the detection of a right atrial pressure (RAP) of > 12 mmHg. [19] The technique has generated considerable interest as a means to guide therapies, and is currently the subject of multi-center prospective trials (ClinicalTrials.gov Identifier: NCT06227702) [20]. One barrier to widespread adoption of VExUS is the difficulty of the renal component, prompting calls for validation of a modified protocol. For this reason, we compared a modified version of the VExUS score excluding renal imaging (mVExUS) to traditional VExUS (tVExUS) for detection of elevated RAP, as well as evaluating each VExUS component.