Inferior Vena Cava and Hemodynamic Congestion

BACKGROUND: Among the indices able to replace invasive central venous pressure (CVP) measurement for patients with acute decompensated heart failure (ADHF) the diameters of the inferior vena cava (IVC) and their respiratory fluctuations, so-called IVC collapsibility index (IVCCI), measured by echocardiography, have recently gained ground as a quite reliable proxy of CVP. OBJECTIVES: The aims of our study were to compare three different ways of evaluating cardiac overload by using the IVC diameters and/or respiratory fluctuations and by calculating the inter-method agreement PATIENTS AND METHODS: Medical records of patients hospitalized for right or bi-ventricular acute decompensated heart failure from January to December 2013 were retrospectively evaluated. The predictive significance of the IVC expiratory diameter and IVC collapsibility index (IVCCI) was analyzed using three different methods, namely a) the criteria for the indirect estimate of right atrial pressure by Rudski et al. (J Am Soc Echocardiogr. 2010); b) the categorization into three IVCCI classes by Stawicki et al. (J Am Coll Surg. 2009); and c) the subdivision based on the value of the maximum IVC diameter by Pellicori et al. (JACC Cardiovasc Imaging. 2013). RESULTS: Among forty-seven enrolled patients, those classified as affected by persistent congestion were 22 (46.8%) using Rudski’s criteria, or 16 (34%) using Stawicki’s criteria, or 13 (27.6%) using Pellicori’s criteria. The inter-rater agreement was rather poor by comparing Rudski’s criteria with those of Stawicki (Cohen’s kappa = 0.369; 95% CI 0.197 to 0.54), as well as by comparing Rudski’s criteria with those of Pellicori (Cohen’s kappa = 0.299; 95% CI 0.135 to 0.462). Further, a substantially unsatisfactory concordance was also found for Stawicki’s criteria compared to those of Pellicori (Cohen’s kappa= 0.468; 95% CI 0.187 to 0.75). CONCLUSIONS: The abovementioned IVC ultrasonographic criteria for hemodynamic congestion appear clearly inconsistent. Alternatively, a sequential or simultaneous combination of clinical scores of congestion, IVC ultrasonographic indices, and circulating levels of natriuretic peptides could be warranted.