Right heart catheterization in heart failure: indications, interpretation, and pitfalls

Authors, Journal, Affiliations, Type, DOI

• Katarina Zeder, Susanna Mak, Nazzareno Galie, Stephan Rosenkranz, Bradley A. Maron
• European Heart Journal (2025) 46:3354–3372
• University of Maryland, University of Toronto, University of Bologna, University of Cologne
• State of the Art Review
• DOI: https://doi.org/10.1093/eurheartj/ehaf322

Overview

This state-of-the-art review provides a comprehensive practical guide to right heart catheterization (RHC) across the full heart failure spectrum — from ambulatory chronic heart failure through acute decompensation, cardiogenic shock, LVAD candidacy, and heart transplantation evaluation. It addresses RHC methodology and common pitfalls in PAWP interpretation, hemodynamic thresholds for each clinical scenario, and contextualisation within the clinical presentation. Future directions including non-invasive PAWP technologies and novel haemodynamic parameters are also discussed.

Keywords

Right heart catheterization, Acute heart failure, Chronic heart failure, Cardiac transplantation, Cardiogenic shock

Key Takeaways

Methodology and Technical Considerations

• RHC should be performed with the patient supine via the right internal jugular vein (preferred); ultrasound-guided access reduces bleeding complications
• Zero-reference must be at the mid-thoracic level (equivalent to the left atrium); 1 cm deviation changes measured pressure by ~0.8 mmHg
• Cardiac output: direct Fick is gold standard; thermodilution is an acceptable alternative (average 3–5 measurements, <10% variability); indirect Fick is less reliable; thermodilution is unreliable with shunts
• All pressures measured at end-expiration; in patients with large respiratory swings (COPD, obesity, mechanical ventilation) average over 3–4 respiratory cycles
• PAWP measured just prior to the C-wave (closest to LVEDP); if C-wave indeterminate, gate to QRS complex; use mean PAWP when large V-waves present (e.g. severe mitral regurgitation)
• PAWP must always be ≤ diastolic PAP; clear A- and V-waves must be visible to confirm correct wedging
• Atrial fibrillation can cause overestimation of PAWP compared to direct LVEDP
• Post-diuresis: PAWP may be falsely low (overestimates PVR); volume-overloaded state: PAWP may be falsely elevated due to ventricular interdependence
• Mixed venous O₂ saturation >75% should prompt stepwise oximetry run to exclude left-to-right shunt
• Safety: serious adverse events ~1.1%, procedure-related mortality ~0.055% in experienced PH centres; most feared complication is PA perforation

PAWP Thresholds and the Zone of Uncertainty

• Normal upper limit of PAWP: 13 mmHg (meta-analysis, n=940 healthy subjects); women have slightly higher normal PAWP than men
• Post-capillary PH defined by PAWP >15 mmHg (current ESC PH guidelines)
• "Zone of uncertainty": PAWP 12–18 mmHg should be contextualised to individual clinical probability of left heart disease; provocative testing may be appropriate in this range
• Exercise RHC: mPAP/CO slope >3 mmHg/L/min defines exercise PH; peak PAWP >25 mmHg diagnoses HFpEF
• PAWP/CO slope >2 mmHg/L/min associated with worse outcomes and clinically diagnosed HFpEF
• Fluid challenge: PAWP ≥18 mmHg after 500 mL rapid saline infusion suggests HFpEF; passive leg raise is a simpler alternative

RHC in Chronic Heart Failure

• PH criterion: mPAP >20 mmHg; PAWP ≤15 mmHg + PVR >2 WU = pre-capillary PH; PAWP >15 mmHg = post-capillary PH (isolated if PVR ≤2 WU; combined if PVR >2 WU)
• Bi-ventricular HF pattern: mPAP ~25–35 mmHg, PAWP >15 mmHg, RAP >8 mmHg, mildly elevated PVR (2–5 WU), reduced LVEF, mild-to-moderate RV dysfunction
• "Right heart predominant" left HF phenotype: mPAP >35 mmHg, PAWP >15 mmHg, RAP >12 mmHg, PVR >5 WU, CI <2.2 L/min/m², severe TR, severe RV failure, cardio-hepato-renal syndrome
• Constrictive pericarditis vs restrictive cardiomyopathy: both show RAP:PAWP >0.5; constrictive physiology shows discordant RAP↑/PAWP↓ with inspiration; restrictive cardiomyopathy shows concordant pressure changes; simultaneous right + left heart catheterisation often required
• ESC Class 2b: RHC may be considered to confirm HFpEF diagnosis in selected patients (may change diuretic or SGLT2i therapy)
• AHA Class 3: routine RHC not recommended to guide HF treatment decisions; may provide useful clinical information in selected patients
• CHAMPION trial: wireless hemodynamic monitoring guided by PAP reduces HF hospitalisations by 33% (ESC Class 2b recommendation)
• RV-PA coupling (Ees/Ea ratio): assessed by conductance RHC or non-invasively via TAPSE/sPAP ratio; identifies RV-PA uncoupling sub-phenotype in chronic left-sided HF; prognostic in HFpEF

RHC in Valvular Heart Disease

• ESC: RHC reserved for inconclusive or discordant non-invasive assessment; if sPAP >50 mmHg is the only criterion for surgical indication, RHC confirmation required
• Severe TR: Doppler gradients may unreliably assess PH severity; RHC with PVR assessment recommended (ESC Class 1 for severe TR pre-intervention)
• Severe primary MR: RHC to confirm PH (sPAP >50 mmHg at rest) when this is the only criterion for surgical referral
• Mitral stenosis: direct pressure gradient measurement indicated if imaging is difficult; AHA Class 1 for RHC at rest and during exercise in characterising LV, LA, and PA haemodynamics
• Aortic stenosis: RHC gold standard for PH diagnosis, which is a strong predictor of mortality in severe AS; improves prognostic power over echocardiography alone (not specifically in ESC guidelines but widely used pre-AVR)

RHC in Acute Heart Failure

• Diamond-Forrester classification (1973): warm/cold (CI cut-off 2.5 L/min/m²) and wet/dry (PAWP cut-off 18 mmHg); still used but ESC 2021 prefers clinical phenotype classification
• Acute LV failure: PAWP >15 mmHg, usually maintained CI (≥2.5 L/min/m²) and blood pressure
• Acute isolated RV failure: PAWP normal/high-normal (<18 mmHg), CI <2.5 L/min/m², RAP >8 mmHg, reduced systemic blood pressure
• Acute bi-ventricular failure: PAWP >15 mmHg, RAP >8 mmHg, CI <2.5 L/min/m², RAP:PAWP >0.5

RHC in Cardiogenic Shock

• SCAI shock stages A–E; all stages B–E involve PAWP >15 mmHg (>20 mmHg in Stage E); CI <2.2 L/min/m² in Stages C–E; RAP >10 mmHg
• Isolated RV cardiogenic shock: RAP strongly elevated (>14 mmHg), PAWP normal/high-normal (<18 mmHg), RAP:PAWP >0.5–0.8, decreased PAPI and CI
• Mixed venous O₂ saturation ≥65% in Stages A+B; decreased in Stages C–E; increased in late-stage septic shock
• Cardiogenic shock haemodynamic profile: low CI, high PAWP, high SVRI ("cold and wet"); vasodilatory shock: high CI, normal PAWP, low SVRI ("warm and dry")
• Isolated RV infarction shock: RAP:PAWP ≥0.8
• Early RHC (within 2 days) in cardiogenic shock: lower AKI incidence (OR 0.69), higher MCS use (OR 1.67), shorter hospital stay vs late RHC (observational data)
• Advanced haemodynamics: PAPI <2.0 and cardiac power output (CPO) <0.6 Watts in SCAI Stage C; RVSWI reflects RV workload; these parameters not yet in European guidelines

RHC in Heart Transplantation

• Class 1 recommendation (ISHLT): RHC prior to listing and periodically every 3–6 months until transplantation
• PAWP >18 mmHg (regardless of CO status) significantly associated with increased waitlist death, delisting, urgent HTX, and LVAD implantation
• Pre-transplant PVR >2.5 WU significantly associated with increased post-HTX mortality (n=26,649; multivariate)
• Prohibitive PH: sPAP ≥50 mmHg + (TPG ≥15 mmHg or PVR ≥3 WU)
• Acceptable vasodilator response: TPG ≤12–15 mmHg + PVR ≤2.5–3 WU + systolic BP >85 mmHg
• If PVR reversible but BP falls <85 mmHg: RV failure risk remains high
• If vasodilator challenge fails: hospitalisation with diuresis/vasoactive therapy → temporary MCS → durable LVAD
• LVADs can improve or reverse PH; if PH persists after 3–6 months of effective LV unloading, considered irreversible → HTX precluded
• Post-HTX RHC: Grade 3 cardiac allograft vasculopathy (75% 5-year mortality) → restrictive physiology (RAP:PAWP >0.5) on RHC can inform re-transplantation decision

RHC in LVAD

• LVAD candidacy criteria: PAWP ≥20 mmHg + systolic BP ≤90 mmHg or CI ≤2.0 L/min/m² (among other factors)
• Pre-implantation: RHC within 1–2 weeks for elective cases; goal RAP ≤12–15 mmHg prior to surgery
• Post-implantation ramp test: optimise LVAD speed; target RAP <12 mmHg and PAWP <18 mmHg; detect thrombosis/malfunction
• RV failure pre-LVAD predictors: RAP >15 mmHg, RAP/PAWP >0.63 (1-year survival 59% vs 78% in those without RV failure)
• PAPI <1.85: 95% sensitivity for post-LVAD RV failure; outperforms RAP, RAP:PAWP, and RVSWI
• LVAD explantation criteria (myocardial recovery): CI >2.6 L/min/m² + RAP <10 mmHg + PAWP <13 mmHg confirmed during serial speed reduction trials (Class 2a)

Future Directions

• Non-invasive PAWP: 4D-flow CMR (r=0.94 with invasive PAWP); lung B-lines (AUC 0.73 for PAWP >15 mmHg); left atrial strain (AUC 0.9); mitral/tricuspid valve opening time difference (moderate sensitivity, high specificity)
• Pulmonary arterial compliance (PAC = stroke volume/pulmonary pulse pressure): PAC ≥3.0 mL/mmHg associated with improved survival in PH; early decrease may identify risk for right heart failure before PVR rises

Limitations of the document

• State-of-the-art review — no original primary data; synthesises observational evidence and guidelines from different eras
• Most cardiogenic shock data associating RHC with outcome benefit is observational; RCT (NCT05485376) ongoing
• Clinical thresholds across scenarios are derived from heterogeneous studies; no single universal threshold exists for many parameters (e.g. PVR for prohibitive PH)
• Vasodilator testing in HTX candidacy: conflicting data on survival benefit; one US study found no benefit with positive vasodilator test
• PAWP zone of uncertainty (12–18 mmHg) lacks validation for fluid challenge provocative testing

Key Concepts Mentioned

• concepts/Right-Heart-Catheterization — central subject of the review
• entities/Pulmonary-Hypertension — classification framework; pre/post-capillary PH; PVR thresholds
• entities/Heart-Failure — acute, chronic, advanced HF haemodynamic thresholds
• concepts/HFpEF — diagnosis via exercise RHC, fluid challenge, passive leg raise; PAWP zone of uncertainty

Key Entities Mentioned

• entities/Heart-Failure — RHC across all HF phenotypes
• entities/Pulmonary-Hypertension — PH classification; treatment implications
• entities/CTEPH — mentioned in context of pre-capillary PH differential

Wiki Pages Updated

• wiki/sources/rhc-hf-ehj-2025.md — created
• wiki/sourceindex.md — updated
• wiki/wikiindex.md — updated (new concept page)
• wiki/concepts/Right-Heart-Catheterization.md — created
• wiki/entities/Heart-Failure.md — updated (RHC section)
• wiki/entities/Pulmonary-Hypertension.md — updated (PAWP methodology and thresholds)