Healthy Individuals. Chronic Congestive Heart Failure: Observations at Abdominal Ultrasound with

Transcription

1 Chronic Congestive Heart Failure: Observations at Abdominal Ultrasound with a Comparison of Abdominal Veins in Healthy Individuals Juri V. Kaude, M.D., F.I.C.A., and Peeter Jakobson, M.D. GAINESVILLE, FLORIDA Abstract Findings observed at abdominal ultrasound in 8 patients with chronic congestive heart failure were hepatomegaly and dilated inferior vena cava which did not change its caliber during respiration. In some cases, distended hepatic or renal veins were also present. In a control group without known hepatic, cardiac, or renal disease, the veins were narrower, and the caliber of the inferior vena cava always responded to respiration, being widest at the end of inspiration and collapsed at Valsalva maneuver. Introduction An occasional patient who is referred for abdominal ultrasound because of suspected hepatocellular or biliary tract disease may have hepatomegaly secondary to heart failure with chronic passive congestion of the liver.1-3 In this communication, we describe ultrasonographic signs of chronic congestive heart failure as reflected from changes in the abdominal veins and compare these with findings in a normal population. Materials and Methods Eight patients who had abdominal ultrasound for a variety of reasons (hepatomegaly, abdominal mass, gallbladder disease, aortic aneurysm, abscess) had chronic congestive heart failure. Three of these had mitral (1 of them also aortic) valve replacement because of rheumatic heart disease. Three patients had long histories of congestive heart failure either secondary to coronary artery disease or hypertensive cardiomyopathy. In 1 patient, the heart failure was caused by chronic anemia (sickle cell disease) and 1 patient had pericarditis. Ultrasonographic evaluations were made in regard to liver From the Department of Radiology, University of Florida College of Medicine, Gainesville, Florida 199

2 200 FIG. 1. Dilated inferior vena cava and right hepatic vein in a patient with chronic congestive heart failure (aortic and mitral valve replacement for rheumatic heart disease). Cardiac catheterization showed elevated right atrial, right ventricular, pulmonary artery, and left ventricular end diastolic

3 enlargement and the appearance of the inferior vena cava and hepatic and renal veins. The findings were correlated witch the patients clinical status, results of ECG, laboratory tests, and chest roentgenograms. One patient had cardiac catheterization. Comparative ultrasonographic measurements of the inferior vena cava in different phases of respiration and during Valsalva maneuver were obtained in 25 healthy individuals. Additionally, the size of hepatic and renal veins was measured in 10 patients without known cardiac, hepatic, or renal disease. The estimations of the liver size were subjective, based upon numerous longitudinal and transverse scans of the liver in every patient. Results All 8 patients with chronic heart failure had hepatomegaly and dilated inferior vena cava. The maximum diameter of the inferior vena cava measured between 2.8 and 3.8 cm (average 3.1 cm) (Figure 1A). There was very little or no variation of the caliber of the inferior vena cava during different phases of respiration or the Valsalva maneuver. The width of the main right hepatic vein in patients with chronic heart failure was between 1.1 and 2.5 cm (Figure 1A). In 2 patients, the left renal vein appeared wide, 1.2 cm throughout its course (Figure 2). In individuals without known cardiac or hepatic disease, the maximum diameter of the inferior cava lumen varied between 1.2 and 3.0 cm (average 1.8 cm) (Figure 3A). There was considerable variance in the diameter of the inferior vena cava during respiration. The lumen was widest at the end of full inspiration. During Valsalva maneuver, the inferior vena cava almost collapsed (Figure 3B). The width of the main right hepatic vein in healthy individuals varied between 0.5 and 1.0 cm (Figure 4). The caliber of a normal left renal vein varies usually along its course, being narrowest in the midline where it crosses over to the right side between the aorta and the superior mesenteric artery (Figure 5). The widest measurements of the left renal vein in normal individuals were to the left in the midline, 0.4 to 0.8 cm, sometimes twice the diameter of the vein in its midportion. Discussion The diagnosis of congestive heart failure is essentially clinical. Abdominal ultrasound performed because of hepatomegaly or abnormal liver function tests or for diagnosis of other co-existing abdominal disease demonstrated pressures. A, the inferior vena cava (I) measures 3.8 cm at its widest point. The right hepatic vein (HV) is dilated to 2.5 cm. The liver (L) is enlarged. (U, level of umbilicus; PV, portal vein; anterior longitudinal scan). B, chest roentgenogram shows cardiomegaly, aortic and mitral valve prostheses, pericardial calcifications, redistribution of pulmonary flow, evidence of chronic failure, and old pleural changes on the right. 201

4 202 FIG. 2. Dilated left renal vein (RV). Patient with rheumatic heart disease and mitral valve replacement (I, inferior vena cava; A, aorta; MA, superior mesenteric artery, MV, superior mesenteric vein; P, pancreas; L, left lobe of the liver; anterior transverse scan). the enlarged liver and distended inferior vena cava in all 8 patients with congestive heart failure. In some cases, the venous engorgement involved hepatic and renal veins. The pathophysiology of chronic congestive heart failure is well known, and the findings on abdominal ultrasound reflect the elevation in venous pressure and chronic passive congestion secondary to right-sided heart failure. In 6 of 8 patients, the widest diameter of the inferior vena cava exceeded the 3.0 cm of maximum width of this vessel observed by us in 1 individual without known heart or liver disease. In 2 patients, the maximum width of the inferior vena cava was 2.8 cm, equal to that found in only 3 of 25 healthy individuals. On the average, the inferior vena cava in patients with congestive heart failure was 70% wider than that in the control group. It has been shown by dynamic ultrasound that in healthy individuals the caliber of the inferior vena cava varies during respiration and at Valsalva maneuver. Our observations in the control group were in agreement with these findings in regard to the increase of the inferior vena cava size at the end of deep inspiration and its decrease during Valsalva maneuver. During inspiration, contrary to the observations of Grant et al,4 the inferior vena cava was wider than at the end of expiration. The fact, however, remains

5 203 FIG. 3. Normal inferior vena cava (anterior longitudinal scans). Top, at the end of inspiration the maximum width of the inferior vena cava (I) is 20 mm. Bottom, during Valsalva maneuver, the inferior vena cava is collapsed, the lumen measuring 8 mm (PV, portal vein; L, liver). that the diameter of the inferior vena cava in healthy individuals is influenced greatly by respiration. The absence or decrease of such variations in patients with chronic congestive heart failure as well as dilatation of the inferior vena cava is apparently caused by elevated pressure of the systemic veins. The elevated venous pressure may in some cases cause distension of hepatic veins. Arbitrarily, we regarded the right hepatic vein wider than 1.0 cm at its entrance to the inferior vena cava as dilated, because in patients without known heart disease the hepatic vein diameter did not exceed this measurement.,. I Ultrasonographically, it is frequently easier to measure the left than the right renal vein because of its longer course (Figure 5). The width of the renal vein varies. It is narrower in its midportion between the aorta and the superior mesenteric artery, and the proximal segment of the left renal vein

6 ._, _ FIG. 4. Normal right hepatic vein (HV) entering the inferior vena cava (I) (anterior longitudinal scan, H, heart; L, liver). FIG. 5. Normal left renal vein (RV). (I, inferior vena cava; A, aorta; arrow, superior mesenteric artery, S, splenic vein; L, liver (left lobe); P, tail of the pancreas; anterior transverse scan). is usually widest in a normal population. 5,6 In both patients with cardiac failure, however, the dilated left renal vein maintained the same caliber, throughout its course (Figure 2). Other causes for distension of renal veins are increased venous flow (arteriovenous fistulae, splenorenal shunts) or neoplastic obstruction.7, 8

7 205 The findings on abdominal ultrasound in the presence of chronic congestive heart failure (hepatomegaly together with dilated inferior vena cava, not responding to respiratory movements, in some cases associated with dilated hepatic or renal veins) are well explained by the pathophysiology of the condition, elevated systemic venous pressure secondary to right-sided heart failure. The findings have been rarely discussed in the literature,1-3, 9 but it is important to recognize them. First, they give additional support to the already clinically diagnosed condition, and second, they may occasionally help to bring the attention of the referring physician from an abdominal condition to the diseased heart. Juri V. Kaude, M.D., F.I.C.A. Box J-374, JHMHC Gainesville, Florida Joseph, A.E.A., Dewbury, K.C., McGuire, P.G.: Ultrasound in the detection of chronic liver disease (the "bright liver"). Br. J. Radiol., 52: 184, Kaude, J.V., Cohen, O.R., Wright, P.G.: Ultraschalldiagnostik bei Erkrankungen des Leberparenchyms. Radiologe, 20: 347, Cohen, O.R., Kaude, J.V., Wright, P.G.: Ultrasonographic findings in hepatocellular disease. Appl. Radiol. (in press), Grant, E., Rendano, F., Sevine, E., et al.: Normal inferior vena cava: Caliber changes observed by dynamic ultrasound. Am. J. Roentgenol., 135: 335, Buschi, A.J., Harrison, R.B., Brenbridge, A.N.A.G., et al.: Distended left renal vein: CT/sonographic normal variant. Am. J. References Roentgenol., 135: 339, Kurtz, A.B., Dubbins, P.A., Zegel, H.G., et al.: Normal left renal vein mimicking left renal artery aneurysm. J. Clin. Ultrasound, 9: 105, Thomas, J.L., Bernardino, M.E.: Neoplasticinduced renal vein enlargement: Sonographic detection. Am. J. Roentgenol., 136: 75, Braun, B., Weilemann, L.S., Weigand, W.: Ultrasonographic demonstration of renal vein thrombosis. Radiology, 138: 157, Weill, F., Maurat, P.: The sign of the vena cava. Echotomographic illustration of right cardiac insufficiency. J. Clin. Ultrasound, 2 : 27, 1974.