Dr Marat Fudim (Duke University School of Medicine, Durham, NC, US) joins us to discuss congestion phenotypes in heart failure, the distinction between true volume overload and maladaptive volume redistribution, and the emerging role of greater splanchnic nerve modulation.

In this interview, Dr Fudim explores one of the most clinically nuanced challenges in heart failure management: differentiating patients who are genuinely fluid-overloaded from those whose decompensation is driven by redistribution of blood volume from the splanchnic compartment into the central circulation. He outlines the bedside, imaging and haemodynamic findings that help characterise the underlying mechanism, drawing particular attention to the neck and shin examination, orthostatic assessment, and the interpretation of filling pressures in patients with minimal or difficult-to-assess oedema.

Interview Questions:

1. When you assess a patient with worsening heart failure, how do you distinguish true fluid overload from maladaptive volume redistribution?
2. Which bedside, imaging or haemodynamic findings most strongly suggest a meaningful splanchnic component to congestion?
3. Are there patients in whom escalating loop diuretics is clearly the wrong strategy, and what typically defines that phenotype?
4. How has your work on the splanchnic compartment changed the way you think about decongestion in everyday practice?
5. What do the emerging data on greater splanchnic nerve modulation tell us so far, particularly in HFpEF?
6. If this approach becomes more widely available, what would sensible patient selection look like in the early years?
7. What are the one or two practical changes clinicians could make immediately when evaluating congestion at the bedside?

Editors: Jordan Rance
Videographer: Oliver Miles, David Ben-Harosh
Support: This is an independent interview produced by Radcliffe Cardiology.