Rethinking Congestion in Heart failure From Volume Overload to Venous Pressure and Organ Disfunction with VExUS

Congestion is the main driver of symptoms, hospitalization, and adverse outcomes in heart failure (HF), yet its clinical assessment remains suboptimal. Traditional ap-proaches, largely focused on estimating intravascular volume through clinical exami-nation, biomarkers, or inferior vena cava assessment, fail to capture the complexity of venous congestion and its impact on organ function. Emerging evidence supports a paradigm shift from a static, volume-centered view to a dynamic, physiology-based model in which congestion is defined by elevated ve-nous pressure, impaired organ drainage, and its interaction with systemic perfusion. In this context, point-of-care ultrasound (POCUS) has gained increasing attention as a tool for bedside evaluation of congestion. The Venous Excess Ultrasound (VExUS) score integrates inferior vena cava assessment with Doppler analysis of hepatic, portal, and intrarenal veins, providing a comprehensive evaluation of systemic venous con-gestion at the organ level. VExUS has been shown to correlate with invasive hemodynamic parameters and to identify patients at increased risk of acute kidney injury, rehospitalization, and mortal-ity. Importantly, dynamic changes in VExUS appear to carry greater prognostic signif-icance than single measurements. This review provides a pathophysiological and clinical paradigm for understanding venous congestion in HF, with a focus on the role of VExUS and multimodal ultrasound. By shifting the focus from fluid quantity to venous pressure and organ perfusion, this approach may improve congestion assessment, risk stratification, and therapeutic guidance.