Heart failure (HF) is a major cause of hospitalization, often leading to acute kidney injury (AKI) due to venous congestion. The Venous Excess Ultrasound (VExUS) score, introduced by Beaubin-Souligny, is a bedside tool for assessing congestion severity and guiding decongestive therapy. VExUS has demonstrated prognostic value in predicting AKI, HF readmission, and mortality. Indeed, guiding decongestive therapy through the VExUS score has been shown to significantly improve the likelihood of achieving faster decongestion. Objectives: This review aims to discuss the potential role of VExUS and analyze the recent findings about its relevance in guiding decongestive therapy in patients with acute decompensated HF. Methods: A comprehensive literature review was conducted, which identified journal articles focused on VExUS and manual reviews of relevant peer-reviewed journals. Conclusions: VExUS is a promising tool for evaluating venous congestion in cardiorenal patients, thereby improving fluid and diuretic management. It provides real-time, non-invasive monitoring that enhances clinical decision-making. However, its accuracy depends on operator expertise, and further research is needed to validate its application across different patient populations.

The assessment of systemic congestion in acute heart failure (AHF) remains clinically challenging, particularly across different left ventricular ejection fraction (LVEF) phenotypes. This study aimed to evaluate whether differences exist in the degree of congestion, assessed through a multimodal approach including physical examination, biomarkers (NT-proBNP, CA125), and point-of-care ultrasound using the Venous Excess Ultrasound (VExUS) protocol, between patients with preserved (HFpEF) and reduced ejection fraction (HFrEF). We conducted a prospective observational study involving 90 hospitalized AHF patients, 80 of whom underwent a complete VExUS assessment. Although patients with HFrEF exhibited higher levels of NT-proBNP and CA125, and more frequent signs of third-space fluid accumulation such as pleural effusion and ascites, no statistically significant differences were found in VExUS grades between the two groups. These findings suggest that the VExUS protocol provides consistent and reproducible information on systemic venous congestion, regardless of LVEF phenotype. Its integration into clinical practice may help refine congestion assessment and optimize diuretic therapy. Further multicenter studies with larger populations are warranted to validate its diagnostic and prognostic utility and to determine its potential role in guiding individualized treatment strategies in AHF.