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35]

CME

Doppler Evaluation of Hepatic Vein Flow

Sita Ram Mittal1
1
Department of Cardiology, Mittal Hospital and Research Center, Ajmer, Rajasthan, India

Abstract
Hepatic vein (HV) flow pattern closely correlates with pressure changes in the right atrium. Normally, there are two forward flow waves – systolic
and diastolic. Diastolic wave is slightly smaller than systolic wave. Three reversal waves can be seen – late systolic, mid‑diastolic, and third
during right atrial contraction. Normally, forward wave velocities increase during inspiration. Reversal waves are slightly more prominent
during expiration. Systolic wave is diminished in atrial fibrillation, right ventricular systolic dysfunction, and tricuspid regurgitation. When these
pathologies are severe or they coexist, systolic wave may reverse. Diastolic wave is diminished in tricuspid stenosis and impaired relaxation
of the right ventricle as seen in right ventricular hypertrophy, right ventricular ischemia, or infarction. Diastolic flow reversal wave becomes
prominent in restrictive cardiomyopathy and pericardial constriction. Reversal wave during right atrial contraction is absent in atrial fibrillation.
It is diminished or absent when compliance of HVs is decreased due to diseases of liver parenchyma. This reversal wave is prominent in each
cardiac cycle in tricuspid stenosis with sinus rhythm and in patients with right ventricular hypertrophy. It is intermittently prominent in the
presence of ventricular ectopics and complete atrioventricular block.

Keywords: Doppler evaluation, echocardiography, hepatic vein, pericardium, right ventricle, right atrium, tricuspid valve

Introduction waveforms. Sample volume (2 mm) is kept inside the HV

Hepatic veins (HVs) drain into the right atrium (RA) through
inferior vena cava (IVC) [Figure 1]. Therefore, HV pressure
and flow pattern closely correlate with pressure changes in
the RA. Right atrial pressures changes are clearly transmitted
to IVC and HVs [Figure 2] even if the Eustachian valve is
well developed. Proximity of HVs to the RA also allows
transmission of pressure changes without significant time
delay. Therefore, HV flow also clearly shows the effect of
respiration on changes in the right atrial pressures. In these
respects, the study of HV flow is superior to study of flow
pattern in superior vena cava.
Method of Recording Hepatic Vein Flow
From the subcostal long‑axis view, IVC is imaged in its long
axis. Slight change in transducer position, exposes one or the
other HV draining into IVC. Usually middle and/or left HV
are seen in this view [Figure 1]. HV draining parallel to the
ultrasound beam is selected. Slight angulation of transducer
helps better alignment with long axis of one of the veins.
A wide angle between ultrasound beam and HV flow results
in decreased flow velocities and blunting of individual
away from IVC. Keeping the sample volume near the junction
with IVC may displace the location of the sample volume with
respiration, and the waveform is also influenced by flow in
IVC. Increased respiratory movement can also displace the
sample volume outside the HV [Figure 3]. In such a situation
recording during apnea allows proper recording of waveforms.
Recording at 50–100 mm/s allows better analysis of waveform.
For evaluation of effect of respiration, recording should be
done at a low speed of 25 mm/s.
If a properly aligned HV is not imaged from subcostal view,
transducer may be moved from subxiphoid area toward the
right midclavicular area. In this view, flow in the middle HV
may be best aligned with the Doppler beam [Figure 4]. If a
properly aligned vein is not visualized even from this window,
patient can be turned in left lateral position and transducer
is moved from subxiphoid area to right midclavicular area.
This may expose a HV parallel to ultrasound beam. In obese
patients, HV may not be visualized form subxiphoid or right
Address for correspondence: Dr. Sita Ram Mittal,
XI/101, Brahmpuri, Ajmer, Rajasthan, India.
E‑mail: drsrmittal@gmail.com

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DOI:
10.4103/jiae.jiae_80_17 How to cite this article: Mittal SR. Doppler evaluation of hepatic vein flow.
J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:53-66.

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Mittal: Hepatic vein flow

Figure 1: Subxiphoid view showing drainage of hepatic vein through Figure 2: Transmission of right atrial pressure changes to the hepatic
inferior vena cava to right atrium. HV: Hepatic vein, IVC: Inferior vena vein through inferior vena cava. RV: Right ventricle. HV: Hepatic vein, IVC:
cava, RA: Right atrium Inferior vena cava, RA: Right atrium

a b
Figure 3: Displacement of sample volume with respiration.
(a) Expiration (exp), (b) inspiration (insp). HV: Hepatic vein, IVC: Inferior
vena cava
Figure 4: Middle hepatic vein imaged from right subcostal region with
midclavicular region. In such situation, an attempt can be made transducer in right midclavicular line. MHV: Middle hepatic vein
to see HV from the right axillary area with the patient in left
lateral position and with index mark of the transducer pointing below the baseline, and retrograde flow (away from IVC and
toward feet.[1] It may reveal right HV in better alignment with toward transducer) is seen above baseline. Following waves
the Doppler beam [Figure 5]. can be seen [Figure 6].
• Systolic forward flow (S). Usually, it is a single wave. At
Mostly HV is not confused with other vascular structures in
times, there might be a notch on the downstroke of the
the liver because of its continuity with IVC and blood flow
systolic wave separating earlier component (S1) from the
away from transducer. However, when HV is imaged from
main systolic wave (S2) [Figure 7]
right midclavicular or right axillary region, its continuity with
• Reversal wave toward end of systole  (systolic reversal
IVC may not be clear. In such situations, HV flow should be
[SR])
differentiated from flow in hepatic artery and portal vein.
• Diastolic forward flow (D)
Flow in both these vessels is toward the transducer (red) and
• Reversal wave after D‑wave  –  diastolic flow reversal
is, therefore, recorded above the baseline as opposed to flow
(diastolic reversal [DR])
in HV which is away from transducer (blue) and is therefore
• Reversal wave during atrial contraction  (atrial
recorded below the baseline. Flow in portal vein is monophasic
reversal [AR]).
and of low velocity. Flow in hepatic artery is pulsatile with
prominent flow in systole and low‑velocity flow in diastole.
Normally, systolic forward flow velocity is slightly more than
diastolic forward flow velocity[2] [Figure 5]. DR velocity is
Normal Waveform in Hepatic Vein Flow usually not very prominent at normal heart rate [Figure 8].
Forward flow (toward IVC and away from transducer) is seen It is usually seen at slow heart rate [Figure 9]. Forward flow

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Mittal: Hepatic vein flow

Figure 6: Hepatic vein Doppler showing normal waves. S: Systolic

Figure 5: Right hepatic vein imaged from right subcostal region with
forward flow, SR: Systolic reversal, D: Diastolic forward flow, DR: Diastolic
transducer along right axillary line. RTHV: Right hepatic vein
reversal, AR: Reversal during right atrial contraction

Figure 7: Hepatic vein Doppler showing two components of systolic

forward flow – S1 and S2. D: Diastolic forward flow, DR: Diastolic reversal, Figure 8: Hepatic vein Doppler showing normal absence of diastolic
AR: Reversal during atrial contraction reversal. S: Systolic forward flow, SR: Systolic reversal, D: Diastolic
forward flow, AR: Reversal during atrial contraction

may not be visible above baseline but is clear as decline in

forward flow.

Hemodynamic Correlates of Hepatic Vein Flow

Figure 9: Hepatic vein Doppler showing normal DR at slow heart rate.
S: Systolic forward flow, SR: Systolic reversal, D: Diastolic forward flow,
DR: Diastolic reversal. AR: Reversal during atrial contraction
velocities increase during inspiration and reversal flows
become slightly prominent during expiration.[2] Reversal flow
HV flow correlates with pressures changes in the RA [Figure 10]
unless there is some destruction in the HV or IVC above the
joining of HV.
Following P‑wave of the electrocardiogram (ECG) the RA
contracts pushing blood into the right ventricle. Right atrial
contraction increases right atrial pressure. This also results in
backflow of blood in the IVC and HV. This produces transient
reversal of flow in the HV Doppler (AR) [Figure 11a]. Right
atrial contraction is followed by right atrial relaxation which
decreases right atrial pressure producing X descent in the right
atrial pressure curve [Figure 9]. This results in slight increase
in flow of blood from IVC to RA. It produces beginning of
forward flow (S‑wave) in the HV Doppler [Figure 11b]. Right

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Mittal: Hepatic vein flow

atrial relaxation is followed by right ventricular contraction

Figure 10: Correlation of pressures changes in right atrium, right ventricle,
and electrocardiogram with hepatic vein flow. Right atrium‑reversal wave
during right atrial contraction coincides with “a” wave in right atrial pressure.
S1 early systolic wave coincides with “X” descent. S2 – late systolic wave
coincides with “X” descent in right atrium. Systolic reversal wave coincides
with V‑wave in the right atrium. Diastolic forward flow (D wave) coincides with
“Y” descent in right atrium. RV: Right ventricle, RA: Right atrium, AR: Atrial
reversal, SR: Systolic reversal, DR: Diastolic reversal, ECG: Electrocardiogram
which coincides with QRS of ECG. Right ventricular
contraction closes the tricuspid valve producing small
C‑wave in the right atrial pressure trace [Figure 10]. This
produces transient mild impairment of flow from IVC to the
RA. Usually, it does not affect HV flow pattern. However,
at times, it can produce a notch on the descending slope of
S‑wave [Figure 11c]. Closure of the tricuspid valve is followed
by contraction of the right ventricle which pulls the tricuspid
annulus and the tricuspid valve down into the right ventricle.
This increases right atrial volume. Right atrial pressure falls
(X descent) [Figure 10] resulting in increased flow of blood
from IVC and HV to RA. Systolic forward flow wave (S) in the
HV becomes more prominent [Figure 11d]. Continued filling
of RA with the closed tricuspid valve increases pressure in
the RA. This reduces flow of blood from IVC and HV to RA
producing downslope of systolic forward flow wave (S‑wave)
in the HV [Figure 12a]. Sometimes this downstroke of S‑wave
may continue above the baseline suggesting mild reversal
of flow in the HV at end systole (SR wave). This coincides
with the end of systole (end of T‑wave of ECG). Onset of
right ventricular relaxation results in fall of right ventricular

a b

c d

Figure 11: Hemodynamics of hepatic vein flow. (a) Right atrium contraction produces backflow in inferior vena cava and hepatic vein producing atrial
reversal wave, (b) RA relaxation produces forward flow in hepatic vein (S1 wave), (c) closure of tricuspid valve produces transient backflow in hepatic
vein separating S1 waveform S2 wave, (d) downward pulling of tricuspid valve during ventricular systole produces forward flow in hepatic vein producing
S2 wave. RV: Right ventricle, RA: Right atrium, AR: Atrial reversal, ECG: Electrocardiogram, IVC: Inferior vena cava, HV: Hepatic vein

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Mittal: Hepatic vein flow

a b

Figure 12: (a) Filling of right atrium produces backflow in hepatic vein producing systolic reversal wave, (b) ventricular relaxation with opening of
tricuspid valve and emptying of right atrium produces diastolic forward flow (D) in hepatic vein, (c) Filling of right ventricle and closure of tricuspid
valve produces diastolic reversal wave. RV: Right ventricle, RA: Right atrium, AR: Atrial reversal, SR: Systolic reversal, DR: Diastolic reversal, ECG:
Electrocardiogram, IVC: Inferior vena cava, HV: Hepatic vein

pressure below right atrial pressure. Tricuspid valve opens
and blood flows from RA to right ventricle. This results in
increased flow of blood from IVC to RA. This coincides with
fall in right atrial pressure (Y descent) [Figure 10]. Forward
flow of blood from HV to IVC increases producing diastolic
forward flow  (D‑wave)  [Figure  12b]. Progressive filling of
right ventricle increases right atrial pressure. Flow from IVC
to RA declines. Forward flow from HV to IVC decreases
producing end of D‑wave in HV flow. Right ventricle
cannot accommodate more blood. Continuing venous return,
therefore, results in mild reversal in mid‑diastole following
the D‑wave (DR) [Figure 12c].
Effect of Respiration
Inspiration decreases intrathoracic pressure. In the presence
of normal pericardium, this fall in intrathoracic pressure is
transmitted to intrapericardial cardiac chambers. There is fall in
pressure in the right atrium and right ventricle. Fall in right atrial
pressure results in increased flow of blood from IVC to the RA.
Blood flow from HV to inferior venal cava increases. Forward
flow velocities, therefore, increase and retrograde flow velocities
decrease [Figure 13a]. Inspiratory increase in retrograde flow
velocities suggests diminished compliance of the right ventricle.
During expiration, intrathoracic pressure increases. Right atrial
pressure increases. Flow from IVC to RA decreases. Forward
flow in the HV decreases, and there is slight increase in reversal
velocities [Figure  13b]. Effect of respiration on HV flow is
shown in Figure 14. Respiration affects amplitude of waves
in HV flow. In Figure 15, onset of inspiration coincides with
diastole of the second cardiac cycle (marked 2). Therefore, in
the second cardiac cycle, diastolic wave is more prominent than
systolic wave, whereas in the third cardiac cycle (marked 3),
systolic wave is more prominent than diastolic wave. Waveforms
of HV flow are, therefore, more correctly analyzed during apnea.
Effect of respiration on HV flow, thus, depends on:
• Magnitude of change in intrathoracic pressure
• Transmission of change in intrathoracic pressure to
intrapericardial cardiac chambers
• Capacity to increase flow across the tricuspid valve during
inspiration
• Compliance of right ventricle to accommodate increased
venous return during inspiration.

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Mittal: Hepatic vein flow

a b

Figure 13: Diagrammatic representation of mechanism of effect of inspiration (a) and expiration, (b) on hepatic vein flow. Peri‑pericardium, HV: Hepatic
vein, IVC: Inferior vena cava, RA: Right atrium, RV: Right ventricle. AR: Atrial reversal, SR: Systolic reversal, DR: Diastolic reversal, ECG: Electrocardiogram

Figure 14: Hepatic vein Doppler showing effect of expiration (EXP) and Figure 15: Hepatic vein Doppler showing effect of onset of inspiration on
inspiration (INSP). S: Systolic forward flow, D: Diastolic forward flow, hepatic vein flow wave form. EXP: Expiration, INSP: Inspiration, AR: Atrial
AR: Reversal during atrial contraction reversal, S: Systolic forward flow, D: Diastolic forward flow

Respiratory excursions are increased in chronic obstructive prevent transmission of changes in intrathoracic pressure to
pulmonary disease. This results in increased respiratory variations intrapericardial RA and right ventricle. Inspiratory increase in
in HV flow. Cardiac tamponade and pericardial constriction forward flow in the HV is thus less than normal [Figure 16].

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Mittal: Hepatic vein flow

a b
Figure 16: Diagrammatic representation of effect of cardiac tamponade on hepatic vein flow in inspiration (a) and expiration (b). Peri-pericardium,
HV: Hepatic vein, IVC: Inferior vena cava, RA: Right atrium, RV: Right ventricle. AR: Atrial reversal, SR: Systolic reversal, DR: Diastolic reversal, ECG:
Electrocardiogram

Significant tricuspid stenosis prevents inspiratory increase in
venous return to be passed on to right ventricle freely during
diastole. This decreases inspiratory increase in diastolic forward
flow in the HV [Figure 17]. If the patient is in sinus rhythm,
forceful right atrial contraction against stenosed tricuspid valve
also results in increased reversal in IVC and HV during atrial
contraction (prominent AR wave). If the patient is in atrial
fibrillation, there is no AR wave. Noncompliant right ventricle
fails to accommodate increased venous return during inspiration.
This results in increase in DR in HV during inspiration.
Respiratory variations are reduced or even lost in following
situations:
• Obstruction in IVC above joining of HV preventing
increase in inspiratory flow to RA [Figure 18a‑1]
• Obstruction in HV preventing inspiratory increase in flow
[Figure 18a‑2]
• Diminished compliance of HV due to disease of
surrounding liver parenchyma [Figure 18a‑3] as in – Fatty
infiltration of liver[3]
• Fibrosis (cirrhosis)[4]
• Tumors.
In this situation, early waveform change is dampening
of the normal, retrograde reversal wave during atrial
contraction.[5] HV flow becomes monophasic or biphasic with
low velocity [Figure 18b]. Monophasic waveform suggests
severe disease as compared to biphasic waveform.[6]
Abnormalities in Hepatic Vein Flow Pattern
Reversal wave during right atrial contraction
a. This wave is absent in atrial fibrillation [Figure 19a and b].
In atrial fibrillation, systolic wave is also reduced due to
the absence of contribution by atrial relaxation. In patients
with fast ventricular rate, diastolic flow reversal wave
may fall just before QRS and should not be confused
with AR wave [Figure 19c]. In atrial flutter, HV flow may
show undulations due to repeated atrial contraction and
relaxation [Figure 20a]. Diastolic wave is normal. Atrial
flutter wave occurring simultaneously with QRS produces
prominent reversal wave [Figure 20b]
b. AR wave is reduced or absent in diseases with diminished
compliance of HVs due to diseases of liver parenchyma[5]
c. AR wave is prominent when RA contracts forcefully
[Figure 21]. It is regularly prominent when RA contracts
forcefully with each heartbeat [Figure 22a]. This
happens in
• Tricuspid stenosis with sinus rhythm [Figure 22b].
In tricuspid stenosis, right ventricle also fills slowly

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Mittal: Hepatic vein flow

a b

Figure 17: Diagrammatic representation of effect of significant tricuspid stenosis on hepatic vein flow Doppler. (a) Right atrial contraction, (b) Right
ventricular contraction, (c) Right ventricular relaxation. RV: Right ventricle, RA: Right atrium, AR: Atrial reversal, ECG: Electrocardiogram, IVC: Inferior
vena cava, HV: Hepatic vein

a
Figure 18: (a) Diagrammatic representation of effect of inferior vena
cava obstruction (1), hepatic vein obstruction (2), and liver disease (3)
on hepatic vein Doppler. (b) Hepatic vein Doppler in liver disease. RV:
Right ventricle, RA: Right atrium, IVC: Inferior vena cava, HV: Hepatic vein,
MHV: Middle hepatic vein, LHV: Left hepatic vein, RHV: Right hepatic vein
during diastole. Amplitude of D‑wave is, therefore,
also reduced with slow deceleration of D‑wave.
Isolated significant tricuspid stenosis is, however,
rare. Most of the time, it is associated with mitral
valve disease, pulmonary hypertension, and atrial
fibrillation. These conditions affect the HV flow.
Tricuspid atresia also produces prominent AR
wave [Figure 22c].
b c
Figure 19: (a) Diagrammatic representation of effect of atrial fibrillation
on hepatic vein flow. S‑systolic forward flow, D: Diastolic forward
flow. There is no atrial reversal wave, (b) Hepatic vein Doppler in atrial
fibrillation. S: Systolic forward flow, D: Diastolic forward flow. There is no
atrial reversal wave, (c) Hepatic vein Doppler in atrial fibrillation. Diastolic
reversal wave resembling atrial reversal wave. EXP: Expiration, INSP:
Inspiration, DR: Diastolic reversal
• Diminished compliance of right ventricle as in
•  Right ventricular hypertrophy
   • Secondary to pulmonary hypertension[2] or
right ventricular outflow tract obstruction
   • Right ventricular hypertrophic cardiomyopathy

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Mittal: Hepatic vein flow

   • Hypertrophy of interventricular septum • Complete atrioventricular block [Figure 24a and b].

   • Right ventricular cardiomyopathy.
• In these conditions, D‑wave is reduced due to slow
filling in the right ventricle
• Atrioventricular nodal reentrant tachycardia
[Figure 22d]. RA contracts when tricuspid valve is
closed due to simultaneous contraction of the right
ventricle.
d. AR wave is intermittently prominent when the RA
intermittently contracts against a closed tricuspid valve
due to simultaneous right ventricular contraction. In such
a situation as the blood cannot go across tricuspid valve,
it comes back into IVC and HV. Such a situation occurs
in:
• Atrioventricular dissociation
• Ventricular ectopics [Figure 23a and b]
When P‑wave falls away from QRS small atrial
relaxation wave can be seen [arrow in Figure 24a]
• P‑wave falling on ST segment [Figure 25a and b]
• In patients with diminished compliance of the right
ventricle, AR may become prominent only during
inspiration [Figure 26].
Systolic forward flow
Usually, it is a single wave. If atrial relaxation component is
prominent, it may separate from the main systolic wave by a notch.

a b
Figure 20: (a) Hepatic vein Doppler in a case of atrial flutter showing
undulations (Marked A) due to repeated atrial contraction and
relaxation. (b) Atrial flutter wave occurring simultaneously with QRS
produces prominent reversal wave. EXP: Expiration, INSP: Inspiration, Figure 21: Hepatic vein Doppler showing prominent atrial reversal wave.
AR: Atrial reversal, D: Diastolic forward flow S: Systolic forward flow, D: Diastolic forward flow. AR: Atrial reversal

a b

c d

Figure 22: (a) Hepatic vein Doppler showing regularly prominent atrial reversal wave. S‑systolic forward flow, D‑diastolic forward flow, (b) Hepatic
vein Doppler showing regularly occurring prominent atrial reversal wave in a case of tricuspid stenosis with sinus rhythm. (S) Systolic wave, Diastolic
wave (D) is reduced, (c) Hepatic vein Doppler from a case of tricuspid atresia showing regularly occurring prominent atrial reversal wave, S‑systolic
wave, (d) Hepatic vein Doppler showing regularly occurring atrial reversal wave in atrioventricular nodal reentrant tachycardia. AR: Atrial reversal, HV:
Hepatic vein

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Mittal: Hepatic vein flow

a a

b b
Figure 23: (a) Diagrammatic representation of intermittently Figure 24: (a) Diagrammatic representation of complete atrioventricular
occurring prominent atrial reversal wave (*) due to ventricular ectopic block producing changing amplitude of atrial reversal wave depending
(premature ventricular contraction), (b) Hepatic vein Doppler showing on relation of P‑wave with QRS. Atrial relaxation wave (arrow) can be
prominent atrial reversal wave (*) following ventricular ectopic seen when P‑wave is away from QRS, (b) Hepatic vein Doppler in a
beat (premature ventricular contraction). PVC: Premature ventricular patient with complete atrioventricular block and pacemaker showing
contraction, AR: Atrial reversal, ECG: Electrocardiogram, S: Systolic intermittent prominent atrial reversal wave (*) and atrial relaxation
forward flow, D: Diastolic forward flow wave (arrow). AR: Atrial reversal, ECG: Electrocardiogram

Figure 26: Hepatic vein Doppler from a patient with right ventricular

dysfunction showing prominent atrial reversal wave only during
inspiration. EXP: Expiration, INSP: Inspiration, AR: Atrial reversal, S:
Systolic forward flow, D: Diastolic forward flow

If PR interval is significantly prolonged, atrial relaxation may

b ventricular systolic dysfunction as in right ventricular
Figure 25: (a) Electrocardiogram showing sinus bradycardia with junctional
rhythm. At times P-wave falls on ST segment (*). (b) Hepatic vein Doppler
showing prominent atrial reversal when P-wave falls on ST segment (*).
AR: Atrial reversal
appear as a separate forward flow wave between reversal wave
due to atrial contraction and systolic forward flow wave. Systolic
forward flow is reduced [Figure 27] in following situations:
1. Loss of atrial relaxation which normally contributes to initial
part of systolic wave. This happens in atrial fibrillation
2. Decrease in systolic downward pull of the tricuspid
annulus and tricuspid valve because of diminished
contractility of the right ventricle. This occurs in right
infarction, massive pulmonary embolism, and right
ventricular dilated cardiomyopathy
3. When extra volume of blood comes to the RA during
systole. This prevents normal flow of blood from IVC.

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Mittal: Hepatic vein flow

This occurs in tricuspid regurgitation (TR) and left blood in the RA progressively increases as systole advances. SR
ventricle to right atrial shunt (Gerbode defect). is, therefore, maximum toward late systole [Figure 28a and b].
Severe the TR, more is the SR[7] [Figure 28c and d]. In the right
Systolic reversal wave ventricular systolic dysfunction, right ventricular and right
When the abovementioned abnormalities are marked or they
coexist, blunting of systolic forward flow can advance to
prominent SR. In TR[2] and Gerbode defect, extra volume of

Figure 27: Hepatic vein Doppler showing reduced amplitude of systolic
forward flow (S), D: Diastolic wave, AR: Atrial reversal wave. AR: Atrial reversal
a b
Figure 29: Diagrammatic representation of early systolic reversal (a) and
forward flow in late systole, (b) in right ventricular systolic dysfunction. RV:
Right ventricle, RA: Right atrium, AR: Atrial reversal, ECG: Electrocardiogram,
IVC: Inferior vena cava, HV: Hepatic vein, ESR: Early systolic reversal, S:
Systolic forward flow, D: Diastolic forward flow

c d
Figure 28: (a) Diagrammatic representation showing mechanism of late systolic reversal in tricuspid regurgitation and Gerbode defect, (b) Hepatic vein
Doppler showing late systolic reversal in a patient with moderate tricuspid regurgitation, (c) Hepatic vein Doppler in a case of severe tricuspid regurgitation
with atrial fibrillation showing pansystolic reversal (systolic reversal), (d) Hepatic vein Doppler in a case of severe tricuspid regurgitation showing pansystolic
reversal. AR: Atrial reversal, LSR: Late systolic reversal, Systolic reversal: Systolic reversal, S: Systolic forward flow, D: Diastolic forward flow, GD: Gerbode
defect, HV: Hepatic vein, IVC: Inferior vena cava, RA: Right atrium, RV: Right ventricle, TR: Tricuspid regurgitation, LA: Left atrium, LV: Left ventricle

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Mittal: Hepatic vein flow

atrial end diastolic pressure are elevated. Closure of tricuspid
valve increases right atrial pressure further. It results in reversal
in early systole. It changes to forward flow as systole advances
and tricuspid valve is pulled down into the right ventricular
cavity [Figure 29]. SR is more prominent during inspiration
due to increased venous return.
Diastolic forward flow
It is related to right ventricular filling in early diastole. This, in turn,
is dependent on fall in right ventricular pressure during diastole
which is dependent on active relaxation of the right ventricle.
Diastolic forward flow is, therefore, decreased when relaxation
of the right ventricle is impaired [Figure 30]. This can occur in:

Figure 30: Hepatic vein Doppler showing diminished diastolic forward Figure 31: Hepatic vein Doppler from a case of pericardial constriction
flow (D) S‑systolic forward flow, AR: Reversal of flow during atrial showing early decelerations of diastolic forward flow (D). S: Systolic
contraction. AR: Atrial reversal forward flow, SR: Systolic reversal, DR: Diastolic reversal. AR: Atrial reversal

a b

Figure 32: Diagrammatic representation of mechanism of diastolic reversal in inspiration (a) and forward flow in diastole in expiration (b) in restrictive
cardiomyopathy. RV: Right ventricle, RA: Right atrium, AR: Atrial reversal, DR: Diastolic reversal, ECG: Electrocardiogram, IVC: Inferior vena cava, HV:
Hepatic vein, Peri : Pericardium

64 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 2  ¦  Issue 1  ¦  January-April 2018
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Mittal: Hepatic vein flow
a b
c Figure 34: Hepatic vein Doppler from a patient of chronic obstructive airway
Figure 33: Diagrammatic representation of effect of respiration on hepatic
vein flow in pericardial constriction. During inspiration (a) interventricular
septum moves to left, During expiration (b) interventricular moves to
right producing diastolic reversal in hepatic vein, and (c) Hepatic vein
Doppler showing expiratory diastolic reversal in a case of pericardial
constriction. RV: Right ventricle, RA: Right atrium, AR: Atrial reversal, DR:
Diastolic reversal, ECG: Electrocardiogram, IVC: Inferior vena cava, HV:
Hepatic vein, Peri : Pericardium, LA: Left atrium, LV" Left ventricle, IVS:
Interventricular septum, S: Systolic forward flow, D: Diastolic forward flow
Figure 35: Hepatic vein Doppler showing additional forward flow wave (?)
after diastolic forward flow (D), S‑systolic forward flow wave
• Right ventricular hypertrophy as in pulmonary artery
hypertension or right ventricular outflow tract obstruction
• Right ventricular ischemia or infarction.
Impaired relaxation of right ventricle results in diminished
filling of the right ventricle in early diastole. This results in
forceful contraction of RA to fill the right ventricle in late
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 2  ¦  Issue 1  ¦  January-April 2018
disease showing forward flow confined to inspiration. AR: Atrial reversal, EXP:
Expiration, INSP: Inspiration, S: Systolic forward flow, D: Diastolic forward flow
Figure 36: Effect of positive pressure ventilation on hepatic vein
flow. RA: Right atrium, IVC: Inferior vena cava, HV: Hepatic vein. AR:
Atrial reversal, DR: Diastolic reversal, SR: Systolic reversal, ECG:
Electrocardiogram, S: Systolic forward flow, D: Diastolic forward flow
diastole. These conditions are, therefore, accompanied by
prominent AR wave in HV flow.
Cardiac tamponade also hampers ventricular filling. It also
results in decreased diastolic forward flow in HV flow. If
intrapericardial pressure is significantly increased, forward
flow may be present only in inspiration.[8]
Normally diastolic forward flow is slightly less than systolic
forward flow.[2] In pericardial constriction, right atrial pressure
is increased due to diminished overall filling of the right
ventricle. Early relaxation of right ventricle is, however,
increased with little or no filling in late diastole. Early filling
of the right ventricle is increased due to rapid relaxation in
early diastole. Diastolic forward flow wave (D) is therefore
slightly more prominent. Deceleration of diastolic forward
flow depends on rate of rise in the right ventricular pressure in
early filing. In tricuspid stenosis, right ventricular filling is slow
resulting in prolongation of D‑wave deceleration. In pericardial
constriction, right ventricular pressure rises rapidly after rapid
early diastolic filling. This resulting in rapid deceleration of
D‑wave in HV flow [Figure 31].
65
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Mittal: Hepatic vein flow
Diastolic flow reversal wave
Maximum filling of the right ventricle occurs in early
diastole (D‑wave of HV flow). Due to filling of right ventricle,
the tricuspid leaflets rise back toward RA. Flow from RA to
right ventricle ceases. Flow from IVC to RA ceases. There is
no forward flow from HV to IVC. There may be mild reversal
of flow in the HV. Conditions which result in restricted filling
of the right ventricle produce prominent diastolic flow reversal
wave.
In restrictive cardiomyopathy, compliance of the right ventricle
is reduced. Right ventricular pressure rises early in diastole
preventing further entry of blood from the RA. This results in
rise in right atrial pressure. However, venous return increases
during inspiration due to fall in intrathoracic pressure. RA
cannot accommodate this increase in venous return . This
results in inspiratory increase in diastolic flow reversal in
HV [Figure 32a]. In expiration, intrathoracic pressure increases
resulting in decreased venous return. This results in decreased
flow reversal [Figure 32b]. Same mechanism operates in other
diseases causing right ventricular diastolic dysfunction.
In pericardial constriction, inspiratory fall in intrathoracic
pressure is not transmitted to intrapericardial right ventricle.
However, right ventricle is able to accommodate inspiratory
increase in venous return due to leftward shift of interventricular
septum[8] [Figure 33a]. In expiration, the interventricular
septum shifts to the right reducing right ventricular volume.
Right ventricle is unable to accommodate the venous return
resulting in expiratory diastolic flow reversal in IVC and
HV[8] [Figure 33b and c].
In chronic obstructive pulmonary disease, there is exaggerated
increase in intrathoracic pressure during expiration. This
results in increased pressure in the right ventricle and RA
resulting in significant decrease or even reversal in HV
flow during expiration. Forward flow may be confined to
inspiration [Figure 34].
Forward flow wave after diastolic reversal wave
Rarely, a small forward flow wave can be seen after diastolic forward
flow wave (D) resulting in triphasic forward flow [Figure 35]. In
patients with prolonged PR interval, it has been attributed to atrial
relaxation wave that follows atrial contraction wave. Mechanism
of the third forward flow wave is not clear. It is possible that
overfilling of the RA toward end‑diastole pushes the tricuspid
66 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 2  ¦  Issue 1  ¦  January-April 2018
valve slightly toward the right ventricle. It can allow transient
increase in forward flow in HV, thus producing third forward
flow wave. Significance of this wave is not clear.
Hepatic vein flow in patients on ventilators
Positive pressure ventilation results in raised intrathoracic pressure.
Pressure on RA and intrathoracic part of IVC rises resulting in
increased back pressure in abdominal part of IVC and HVs.
Flow in HVs is, therefore, reduced. Reduction and redistribution
of cardiac output also result in decreased blood supply to liver.[9]
This also results in decreased flow in HV. These factors result in
decreased velocity of systolic and diastolic forward flow waves
and mild increase in reversal waves [Figure 36].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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