the pulse wave doppler interrogation of the hepatic veins

1. Manifestations of
Cardiovascular Disorders
on Doppler Interoggation
of the Hepatic veins
Bahaa M. Fadel et al. Doppler Interrogation of the hepatic veins
JACC Imaging; 12 (09) 2019: 1872-7.
https://doi.org/10.1016/j.jcmg.2019.01.028
Dr. Nagula Praveen

2. Hepatic veins
• Standard conduits for the assessment of systemic venous
filling of the right heart (wide angle of interrogation of IVC
flow from transthoracic windows).
• Blood flow in the HVs is dependent on
• the cardiac cycle
• the function of the right heart
• influenced by the respiratory cycle and
• the compliance of the liver parenchyma.
• Therefore Hepatic venous flow is altered in above states.

3. Normal hepatic venous flow
• Phasic and bidirectional
• Predominantly antegrade
• Fluctuations in flow direction and velocity reflect changes in
right atrial pressure.
• Eustachian valve does not restrict blood flow into the right
atrium
• flow in HVs reflect the right atrial filling throughout the
cardiac cycle and right ventricular filling during diastole.

4. The hepatic veins drain blood from the liver posteriorly into the
retrohepatic inferior vena cava (IVC), 2 to 3 cm caudal to its junction with the
Right atrium (RA).
The left hepatic vein (LHV) and middle hepatic vein (MHV) drain the left lobe,
Right hepatic vein (RHV) drains the right lobe of liver.
Most often the MHV – offers the best alignment of flow with the doppler
beam from the subxiphoid window.

5. Normal HV doppler
• Normal flow profile in HVs demonstrate phasic and bidirectional
waveforms that are temporally related to the waves obtained on
the pressures recording in the RA.

6. Waveform Phase of
cardiac cycle
Positive/negative Terminology on
doppler
Waveform on
RA pressure
Physiology
Large antegrade
waveform
Early and mid
systole
Negative velocity S wave x descent Atrial relaxation
Systolid
displacement of
tricuspid annulus
towards RV
apex
Small retrograde
waveform
Late systole Positive velocity V wave v wave
Antegrade
waveform
Early and mid
diastole
Negative velocity D wave y descent Follows TV
openIng and
emptying of RA
into RV
Retrograde
waveform
Late diastole Positive velocity A wave a wave Atrial contraction
Rise in RA
pressure more
than IVC

7. Phase of
respiration
Extrcardiac and
intrcardiac
pressures
Systemic
venous
return
Effect Reason
Inspiration
↓ ↑
Increase in S and
D waveforms
Normally compliant right heart
chambers able to accommodate
the augmented preload without
increase in filling pressures
Expiration
↑ ↓
Reduced S and D
waveforms
Increase in
diastolic flow
reversals
More pronounced on the first
cardiac cycle following the onset
of expiration
Rapid shift and sudden increase
of the intrathoracic pressures

8. Optimal recording of the HV doppler

9. Tricuspid valve disease

10. • Constrictive pericarditis
• Exaggerated interdependence between LV and RV due to noncompliant pericardium.
• Augmented S and D waves in inspiration (left ward shift of IVS)
• Augmented flow reversals during expiration (right ward shift of IVS)
• Characteristic pattern is seen with every respiratory cycle.

11. • Restrictive cardiomyopathy
• Increased stiffness of RV and LV
• Increased RV filling pressures due to noncompliant RV.
• Prominent diastolic flow reversals during inspiration.

12. • Elevated right ventricular end diastolic pressure
• pulmonary hypertension,RV, pulmonary valve
• Prominent A wave with high peak velocity and prolonged
duration.

13. • RV systolic dysfunction
• Attenuated s wave – longitudinal function of the RV – a
reduction in RV systolic function causes blunting of the S
wave.
• Prominent D wave

14. • Atrial fibrillation
• Loss of atrial contraction and relaxation
• Absent A wave
• Blunted S wave and dominant D wave

15. • Atrioventricular dissociation
• Large reversal waves
• Asynchronous ventricular pacing and underlying sinus rhythm
• CHB
• VT
• PVCs

16. • Pulmonary hypertension
• Prominent A wave
• Absent D wave

17. • COPD
• Changes in intrathoracic pressures irrespective of the
phase of the cardiac cycle.

18. • Obesity
• No a wave and v wave from reversals due to loss of liver
compliance.

19. • Cirrhosis
• Low velocity monophasic flow

20. Thank you