Pulmonary POCUS · Doppler Lab
Hepatic Vein Waveform: ECG, CVP and Doppler
Live model. Adjust RA pressure, tricuspid regurgitation, rhythm and rate; changes appear on the next beat.
Heart rate
--bpm
Mean RAP
--mmHg
HV S/D
--
HV pattern
--
VExUS grade
--
Systole (tricuspid closed)
Diastole (tricuspid open)
Doppler: below baseline = flow away from the transducer, toward the IVC and heart (antegrade). Above baseline = flow toward the transducer, away from the heart (retrograde).
Controls
Mean right atrial pressure 5 mmHg
Tricuspid regurgitation
Rhythm
Heart rate 65 bpm
Playback speed
Sweep window
Current beat
How to read the waveforms
| Event | CVP | Hepatic vein Doppler |
|---|---|---|
| Atrial contraction (after P wave) | a wave | a wave: brief retrograde flow, above baseline |
| Early systole: tricuspid closes and bulges | c wave | Transition from a to S |
| Systole: atrial relaxation and descent of the tricuspid annulus | x descent | S wave: antegrade, below baseline |
| End systole: RA fills against closed tricuspid (end of T wave) | v wave | v wave: small, at or slightly above baseline |
| Early diastole: tricuspid opens, RA empties | y descent | D wave: antegrade, below baseline |
- Spectral display: hepatic venous flow is laminar, so the spectrum is a narrow band with a clear window beneath it. The brightest band is the modal velocity (the velocity of most red cells); the outer edge is the peak velocity.
- Normal pattern: S deeper than D. Doppler velocity tracks the descents: the x descent drives S and the y descent drives D.
- Rising RA pressure with a stiff, full RA blunts the x descent first, so S shrinks until S < D, while a prominent y descent keeps D large.
- With systolic reversal, the a wave and reversed S fuse into one large retrograde wave above the baseline, followed by an isolated antegrade D wave.
- Tricuspid regurgitation fills the RA during systole: the x descent is replaced by a large c-v wave, and S blunts, then reverses (above baseline) when severe.
- Atrial fibrillation removes the a wave on both tracings and blunts S, so S < D can occur without congestion.
- VExUS hepatic vein grading: normal S > D; mildly abnormal S < D; severely abnormal S reversal. It is applied only when the IVC is greater than 2 cm and is integrated with portal and intrarenal venous Doppler.
- Other confounders: cirrhosis can flatten the waveform; positive pressure ventilation and pericardial disease alter the pattern. Always correlate with the ECG.
References
- McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. RadioGraphics. 2011;31(1):161-188.
- Scheinfeld MH, Bilali A, Koenigsberg M. Understanding the spectral Doppler waveform of the hepatic veins in health and disease. RadioGraphics. 2009;29(7):2081-2098.
- Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with point-of-care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12:16.
Schematic educational model. Waveform timing follows the cited physiology; amplitudes and velocities are representative, not patient specific. pulmonarypocus.com