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Aldama JCG, Rodriguez KHL, Fernández OAM. Venous Excess Ultrasound in Acute Pulmonary Embolism Reflects Right Ventricular Uncoupling Rather Than Congestion. https://doi.org/10.1016/j.arbres.2026.07.003
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pepeska01@hotmail.com
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To the Director,
We read with great interest the prospective cohort study by Gimena-Rodríguez et al. [1] evaluating the Venous Excess Ultrasound (VExUS) protocol in patients with acute pulmonary embolism (PE). We commend the authors for exploring noninvasive hemodynamic tools in this population. However, we would like to raise important conceptual and methodological considerations regarding the interpretation of venous congestion in this setting.
First, defining VExUS as a marker of systemic congestion or associating it with volume overload in PE represents a pathophysiological pitfall. As emphasized by Guinot [2] and Rola et al. [3], VExUS is not a direct measure of intravascular volume. Instead, it serves as an alarm signal for cardiac-driven congestion, reflecting the complex interplay between venous return and right ventricular (RV) function. In acute PE, the abrupt increase in pulmonary vascular resistance leads to extreme pressure overload. The abnormal hepatic and portal venous flows reported by the authors are retrograde manifestations of this afterload mismatch and ensuing RV failure, rather than isolated hypervolemia.
Second, the study evaluates the consequence, venous excess, without assessing the underlying mechanism: right ventricular–pulmonary arterial (RV-PA) coupling. The authors did not report echocardiographic metrics of RV-PA coupling, such as the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). As validated by Tello et al. [4] against invasive pressure-volume loops, TAPSE/PASP is a robust noninvasive surrogate for the end-systolic to arterial elastance (Ees/Ea) ratio. Furthermore, Yuriditsky et al. [5] recently demonstrated that, in acute PE, a TAPSE/PASP ratio<0.34mm/mm Hg strongly discriminates RV-PA uncoupling and is a powerful independent predictor of reduced cardiac index and normotensive shock. Without integrating RV-PA coupling indices, the isolated interpretation of VExUS in acute PE remains physiologically incomplete.
Finally, methodological limitations restrict the generalizability of the authors’ findings. The high-risk cohort was underpowered, comprising only 6 patients (7.5%). Crucially, in 5 of the most severe cases, ultrasonography was performed after reperfusion therapies, with a median delay of 11h. Assessing the VExUS score hours after relief of pulmonary obstruction alters the baseline RV-PA coupling phenotype. Furthermore, the lack of hard clinical outcomes, such as acute kidney injury or mortality, and the violation of the proportional odds assumption in the primary statistical model limit the prognostic applicability of the scale.
Conclusions
Although VExUS is a valuable bedside tool, its application in acute PE must shift from a volume assessment paradigm to a holistic evaluation of RV-PA uncoupling. We advocate for future studies integrating VExUS with TAPSE/PASP to fully decode the hemodynamic catastrophe of acute pulmonary embolism.
Declaration on the use of generative artificial intelligence and AI-assisted technologies in the manuscript preparation process
During the preparation of this work, the authors used generative artificial intelligence technology to improve the academic English language and readability of the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Funding
None declared.
Conflicts of interest
None declared.
Acknowledgments
The authors especially thank Dr. Mario Arturo Carrasco Flores and Dr. Juan Ángel Morales Ferrer for their input and contributions to the preparation of this article.
References
[1]
F.J. Gimena-Rodríguez, P. Bermejo-Acevedo, P. de Peralta-García, M. Yebra-Yebra, I. Quijano-Contreras, S. López-Cuenca,
et al.
Venous Excess Ultrasound Score (VExUS) association with disease severity in acute pulmonary embolism.
Arch Bronconeumol, 62 (2026), pp. 374-380
http://dx.doi.org/10.1016/j.arbres.2026.02.005 | Medline
[2]
P.G. Guinot.
VExUS score: optimizing its use in perioperative and critical care management.
Crit Care, 29 (2025), pp. 472
http://dx.doi.org/10.1186/s13054-025-05687-y | Medline
[3]
P. Rola, W. Beaubien Souligny, K. Haycock, R. Spiegel, A. Denault.
VExUS and right ventricular to pulmonary artery uncoupling.
Crit Care, 30 (2026), pp. 56
http://dx.doi.org/10.1186/s13054-025-05806-9 | Medline
[4]
K. Tello, J. Wan, A. Dalmer, R. Vanderpool, H.A. Ghofrani, R. Naeije,
et al.
Validation of the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio for the assessment of right ventricular-arterial coupling in severe pulmonary hypertension.
Circ Cardiovasc Imaging, 12 (2019),
http://dx.doi.org/10.1161/CIRCIMAGING.119.009047
[5]
E. Yuriditsky, R.S. Zhang, P. Zhang, R. Postelnicu, A.A. Greco, J.M. Horowitz,
et al.
Right ventricular-pulmonary arterial uncoupling as a predictor of invasive hemodynamics and normotensive shock in acute pulmonary embolism.
Am J Cardiol, 236 (2025), pp. 1-7
http://dx.doi.org/10.1016/j.amjcard.2024.10.036 | Medline
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