Here are spectacular images of massively dilated inferior vena cava and hepatic veins in a patient with severe tricuspid regurgitation shared by Dr. Robert Jones.

Below is a related case where patient had ‘pulsatile’ inferior vena cava from severe tricuspid regurgitation. Note the hepatic-vein IVC confluence and its’ entry into right atrium suggesting the pulsatile vessel is not the aorta. Can be difficult to distinguish in suboptimal images, where pulsed wave Doppler demonstration of arterial vs venous waveforms will help. The etiology of tricuspid regurgitation in this case was valve destruction due to endocarditis. Reference: Patel KD, et al. CASE (Phila). 2017.

Pulsatile IVC is also frequently seen in hyperdynamic hearts (e.g. sepsis, cirrhosis, post-heart transplant etc). Be careful not to confuse it with aorta or some artery just based on the pulsatility. Here is a nice example, where IVC (circled) is more pulsatile than the aorta (A).