Relationship between high VExUS score and echocardiographic parameters: a systematic review and meta-analysis

Background: The Venous Excess Ultrasound (VExUS) score integrates inferior vena cava diameter and venous Doppler findings to quantify congestion. Findings are conflicting regarding whether higher VExUS grades reflect worse cardiac function. We conducted a systematic review and meta-analysis to evaluate echocardiographic changes across different VExUS grades and their clinical significance. Methods: The systematic review and meta-analysis were performed in accordance with the PRISMA guidelines, including hospitalized patients assessed with the VExUS score and echocardiography. The primary outcome was the association between high VExUS (grades 2–3) and TAPSE. Secondary outcomes explored the association between VExUS and other echocardiographic parameters in different subpopulations. Eligible studies were randomized or observational. The risk of bias was assessed using the ROBINS-I tool. Results: Eight studies were included in the primary outcome analysis. Patients with high VExUS scores had significantly lower TAPSE values compared to those with low scores, with a pooled mean difference of −2.35 mm (95% CI −3.27 to −1.42; p < 0.00001). Moderate heterogeneity was observed (I2 = 61%), but the overall effect remained robust. Secondary outcomes showed consistent associations between high VExUS scores and reduced cardiac output, stroke volume, RV S′, and LVOT VTI. However, in a sensitivity analysis excluding studies enrolling patients with heart failure, no significant association was observed between higher VExUS scores and right ventricular dysfunction. Moreover, the pooled mean values of right heart parameters (TAPSE, S′, and RV FAC) in patients with VExUS 2–3 remained within normal physiological ranges, suggesting preserved right ventricular function despite venous congestion. Conclusion: This systematic review and meta-analysis demonstrate that patients with venous congestion, as assessed by the VExUS score, may exhibit lower values of echocardiographic parameters of right ventricular function. This association is observed particularly in the subgroup of patients with known cardiac dysfunction and is not present in patients without heart failure. These findings suggest that the VExUS score should be primarily interpreted as a marker of established systemic venous congestion, rather than as an indicator of intrinsic right ventricular systolic impairment.