Normal hepatic vein Doppler

The hepatic veins have a characteristic spectral Doppler waveform. Alterations in the normal hepatic vein waveform may reveal or confirm abnormalities in the heart or liver.

Terminology

The key factor in the shape of the hepatic vein spectral Doppler waveform is the motion of the heart. Multiple terms have been used to describe the hepatic vein waveform, including "phasic", "triphasic", "tetrainflectional", and "periodic". Some prefer the term "periodic" since the term "triphasic" already has a specific application in arterial spectral Doppler waveforms and since "periodic" suggests that the waveform is transmitted by cardiac motion rather than systolic flow.

Radiographic features

The normal periodic hepatic vein waveform is typically described in four parts:

• a wave: atrial contraction
  • normally, peak retrograde movement of blood away from the heart as blood flows from the right atrium both into the right ventricleand with and with a small component of flow reversed into the IVC and hepatic veins
  • the small reversal of flow typically results in a small wave above the baseline, reversed from the overall net flow back to the heart

• s wave: ventricular systole
  • right ventricle contraction results in negative pressure in the right atrium
  • blood flows quickly from the hepatic vein / IVC into the right atrium
  • this is typically the largest wave in the waveform

• v wave: atrial overfilling
  • a transitional inflection point
  • as blood fills the right ventricle, the flow from the hepatic veins and IVC slows, resulting in the s wave returning back to baseline
    • if the atrium fills to capacity then there may be a small amount of flow "recoil" backward, resulting in a v wave that rises above the baseline

• d wave: tricuspid valve opening
  • as the tricuspid valve opens, blood flows from the right atrium into the right ventricle, resulting in a net flow of blood away from the liver and the waveform again dives back down below the baseline
  • this wave is almost always lower in magnitude than the s wave

Sometimes a c wave occurs as a second small inflection above the baseline, right after the a wave, reflecting the effect of the tricuspid valve bulging into the right atrium.

Differential diagnosis

Alterations in the normal hepatic venous Doppler waveform often indicates cardiac dysfunction, although it may also reflect liver disease

• tricuspid regurgitation on Doppler
  • diminished or reversed s wave
  • exaggerated a and v waves
• congestive heart failure on Doppler
  • exaggerated a and and v waves

• decreased hepatic venous Doppler phasicity
  • cirrhosis
  • hepatic veno-occlusive disease (e.g. Budd-Chiari)