Introduction: Focused cardiac ultrasound (FoCUS) is a simplified application of echocardiography mainly based on visual impression (1). Unlike comprehensive standard echocardiography, FoCUS can be successfully performed after rather short training and in much less examination time. By adding FoCUS to physical examination physician can achieve additional information for better understanding of patient’s pathophysiology. Liver congestion due to weak heart may be the cause of liver failure. Liver congestion and impaired heart function can be detected by FoCUS.

Case reports: Case 1: 54-year-old male was transferred from Gastroenterology Ward to Intensive Care Unit (ICU) due to general clinical worsening with encephalopathy and oliguria. No liver or heart problems were known from the history. He has been taking duloxetine for depression. Duloxetin is known as an agent with potential risk for liver lesion (2). Laboratory workup revealed lactate 8.4 mmol/L, bilirubin 86 mmol/L, INR > 6.0, AST 9302 U/L, ALT 6549 U/L. FoCUS performed by an intern, who recently attended Ultrasound Life Support Basic Level (USLS-BL1) course, demonstrated dilated inferior vena cava and hepatic veins as well as significant heart enlargement with reduced left ventricular systolic function. Transoesophageal echocardiography showed biventricular non-compaction cardiomyopathy (3). Left ventricle ejection fraction was 20%. By treating congestive heart failure and stopping duloxetine, liver function and mental state improved. The patient was transferred to Cardiology Clinic for follow-up and treatment. Case 2: 44-year-old male was transferred to ICU due to acute liver failure. Lactate was 12.1 mmol/L, bilirubin 69 umol/L, INR 2.79, AST 1648 U/L, ALT 1996 U/L. Three months before, he was hospitalized in another institution due to bilateral lung infiltrates. When the analysis of sputum demonstrated Mycobacterium bacillus, antituberculotic therapy was started. Bicuspid aortic valve and left ventricle EF of 40% were found on echocardiography. Again dilated inferior vena cava and hepatic veins as well as significant heart enlargement with reduced systolic function were found by FoCUS. Hence, echocardiography was performed and showed severe aortic stenosis and left ventricle EF of 20%. After treating congestive heart failure and discontinuing antituberculotics liver function improved. Few weeks later he underwent aortic valve replacement.

Conclusion: In these two cases liver congestion due to heart failure was recognized by FoCUS performed by an intern, and was as a significant contributing causative factor which influenced on further diagnostic process and treatment. Young physicians, interns and medical students should be encouraged to access the ultrasound training to accept ultrasound as a precious tool in routine patient examination.