What is the significance of reflux of contrast into the Inferior Vena Cava (IVC) and hepatic vascular system, which can be seen in the setting of right ventricular dysfunction, valvular disease, or arrhythmia?

From the Guidelines

Reflux of contrast into the inferior vena cava (IVC) and hepatic vessels during imaging studies is a nonspecific finding that can indicate right-sided heart dysfunction, and further cardiac evaluation, including echocardiography, is recommended to assess right ventricular function, valve competence, and rhythm abnormalities. This phenomenon occurs when blood flow is impeded from entering the right side of the heart, causing backward flow into the venous system. Right ventricular dysfunction can result from several cardiac conditions, including valvular heart disease (particularly tricuspid regurgitation or pulmonary valve stenosis), arrhythmias (especially atrial fibrillation or flutter), or primary right heart failure. When the right ventricle cannot efficiently pump blood forward, pressure increases in the right atrium, leading to elevated central venous pressure and subsequent reflux of blood and contrast material into the IVC and hepatic veins during imaging.

Some key points to consider in the evaluation and management of right-sided heart dysfunction include:

• The use of echocardiography as the first-line imaging modality to assess right ventricular function, valve competence, and rhythm abnormalities 1
• The importance of evaluating right ventricular function, as it is a key determinant of prognosis in patients with heart failure 1
• The use of cardiac magnetic resonance (CMR) imaging to evaluate right ventricular morphology and function, as well as to assess for signs of pulmonary hypertension 1
• The potential role of other imaging modalities, such as cardiac computed tomography (CT) and positron emission tomography (PET), in the evaluation and management of right-sided heart dysfunction 1

Management of right-sided heart dysfunction depends on identifying and treating the underlying cause, which may include medications for heart failure, antiarrhythmic therapy, or valve interventions as appropriate. Echocardiography is a crucial tool in the diagnosis and management of right-sided heart dysfunction, and should be used in conjunction with other imaging modalities and clinical evaluation to guide treatment decisions. According to the 2019 European Association of Cardiovascular Imaging expert consensus document, echocardiography is the "first step" imaging technique for evaluating patients with suspected dilated cardiomyopathy, and provides valuable information on anatomy, function, and hemodynamics 1.

From the Research

Reflux of Contrast into the IVC and Hepatic Vascular

• Reflux of contrast into the inferior vena cava (IVC) and hepatic vascular is a finding that can be seen on computerized tomographic pulmonary angiogram (CTPA) [ 2 ].
• This finding is nonspecific but can be associated with right ventricular dysfunction, valvular disease, and arrhythmia [ 2 ].

Associated Diagnoses

• Extensive reflux of contrast medium into the IVC has been associated with pulmonary hypertension, history of congestive heart failure, chronic atrial fibrillation, and acute pulmonary embolism [ 2 ].
• Reflux of contrast into the IVC is also a predictor of 24-hour and 30-day mortality in patients with acute pulmonary embolism [ 3 ].

Right Ventricular Dysfunction

• Right ventricular dysfunction can be assessed using various imaging modalities, including MRI and echocardiography [ 4 ].
• Echocardiography can be used to evaluate right ventricular function and guide hemodynamic and respiratory therapy in critically ill patients [ 5 ].
• Novel echocardiographic techniques, such as three-dimensional right ventricular imaging and tissue deformation imaging, may improve the diagnostic and prognostic performance of echocardiography in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy [ 6 ].

Clinical Implications

• The presence of reflux of contrast into the IVC and hepatic vascular on CTPA should prompt further evaluation for underlying right ventricular dysfunction or other associated diagnoses [ 2 ].
• Clinicians should consider the potential clinical implications of this finding and correlate it with clinical data and other diagnostic tests [ 2 ].