#right-heart-catheterization #pulmonary-hypertension #heart-failure #cardiogenic-shock #advanced-heart-failure

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

Data From Embedded Figures

The source PDF renders its graphical abstract and all six figures as images, not selectable text, so their content is not machine-readable in raw/RHC-HF-EHJ-2025.md. Each has been read and transcribed below, with the image embedded alongside so the visual and the data are both available. Several of these carry haemodynamic cut-offs that the running text states only in part — notably the full six-phenotype chronic HF table (Figure 3), the two LV sub-branches of acute HF (Figure 4), and the complete SCAI stage values with lactate thresholds (Figure 5).

Graphical Abstract — RHC Across the HF Spectrum

Direction of change in haemodynamic variables by ventricle and scenario (↑ increased, ↓ decreased, → unchanged):

Ventricle	Acute heart failure	Cardiogenic shock	Chronic heart failure
Left	PAWP ↑, CI →	PAWP ↑, CI ↓, PAPI ↓	PAWP ↑, CI →
Right	PAWP →, CI ↓, RAP ↑, RVSWI ↓	PAWP →, CI ↓, RAP ↑, RVSWI ↓, RAP:PAWP ↑	PAWP →, CI ↓, RAP ↑, PVR ↑
Bi-ventricular	PAWP ↑, CI ↓, RAP ↑, RAP:PAWP ↑	PAWP ↑, CI ↓, RAP ↑, RAP:PAWP ↑	PAWP ↑, CI ↓, RAP ↑, RAP:PAWP ↑

Advanced heart failure: LVAD candidacy (PAWP ↑, CI ↓) → invasive ramp test (reduce RAP and PAWP) → cardiac recovery assessment (confirmed normal haemodynamics) → outcome post-LVAD (RVSWI ↓, PAPI ↓, RAP ↑, RAP:PAWP ↑)
Heart transplantation: HTX candidacy — potentially prohibitive PH → vasodilator challenge, diuresis, vasoactive therapies, LVAD → acceptable haemodynamics (→ list) or palliative care. Post-HTX: diagnostic work-up of grade 3 cardiac allograft vasculopathy → RAP:PAWP ↑ → re-transplantation?
Additive tools: exercise testing, fluid challenge, passive leg raise, RV–PA coupling
Important considerations: contextualising haemodynamics with the patient's presentation as a whole; methodology (respiratory swings, zero reference, body position); timing of RHC; patient volume status
Future considerations: novel non-invasive tools; novel parameters

Figure 1 — RHC Waveform Patterns (six panels)

Panel	Finding	Pressure scale
A	Normal PA wave	0–30 mmHg
B	Normal RA and PAWP wave — a, c and v waves identified in both	0–15 mmHg
C	Severe mitral regurgitation — PAWP with large V-waves	0–75 mmHg
D	Correct wedging — the PA trace transitions to a PAWP trace	0–30 mmHg
E	Overwedging due to balloon overinflation — PA to overwedging; pressure is too high and the trace loses its typical shape	0–80 mmHg
F	Large respiratory swings during hyperventilation — PAWP varies markedly between expiration and inspiration	0–20 mmHg, * = end-expiration

The panels are the visual basis for the page's waveform rules: correct wedging requires visible A- and V-waves and PAWP ≤ diastolic PAP (panels A, B, D); large V-waves mandate using mean PAWP (panel C); overinflation (panel E) and respiratory swing (panel F) are the two commonest artefacts that produce a falsely high PAWP

Figure 2 — The Central Role of PAWP in Chronic Heart Failure

How RHC technique determines the PAWP value — "significantly influences PAWP":

RHC factor	Recommendation
Position	Supine
Zero reference	Midthoracic (= left atrium)
Respiratory pressure tracing	End-expiration (without breathing-holding manoeuvre); average ~3–4 respiratory cycles in obesity, COPD, exercise
Cardiac cycle	End-diastole
Volume status	Overloaded? Post-diuresis?
No or unplausible PAWP	Complete occlusion? Over-wedged? Consider direct LVEDP measurement

Clinical thresholds — "contextualising PAWP in the whole clinical profile":

Category	PAWP	PVR
Normal	< 12–13 mmHg, dependent on sex	—
Isolated post-capillary PH	> 15 mmHg	≤ 2 WU
Combined pre- and post-capillary PH	> 15 mmHg	> 2 WU

Grey zone: PAWP 12–15 mmHg, up to 18 mmHg at rest

Latent HFpEF — "possible early diagnosis":

Provocation	Threshold	Interpretation
Exercise testing	Peak PAWP > 25 mmHg	Diagnostic of HFpEF
Exercise testing	PAWP/CO slope > 2 WU	Suggestive of HFpEF
Fluid challenge (500 mL saline)	PAWP > 18 mmHg	Suggestive of HFpEF
Passive leg raise	PAWP ≥ 19 mmHg	Suggestive of HFpEF

Therapy: treat HFpEF, HFrEF and valvular heart disease according to current guidelines. Pulmonary vasodilators are not recommended in PAWP > 15 mmHg outside clinical trials — stated in the figure as "Pulmonary vasodilators only in PAWP ≤ 15 mmHg!"

Figure 3 — Chronic Heart Failure: RHC Variables by Phenotype

The fullest version of this classification in the paper, and the source of the page's chronic-HF criteria. Six phenotypes across two rows of data:

	Isolated left: mild	Isolated left: moderate–severe	Isolated right: mild	Isolated right: moderate–severe	Left side with right heart predominant	Biventricular
Etiology	HFrEF, HFpEF, aortic or mitral valve disease, obstructive hypertrophic cardiomyopathy	(as left)	Pulmonary vascular disease (PAH, CTEPH, PH associated with chronic lung disease)	(as right)	HFrEF, HFpEF, aortic or mitral valve disease, obstructive hypertrophic cardiomyopathy	Cardiac amyloidosis, obstructive hypertrophic cardiomyopathy, pericardial disease
mPAP	> 20 mmHg	> 25 mmHg	> 20 mmHg	> 25 mmHg	> 35 mmHg	> 20 mmHg
PAWP	> 15 mmHg	> 15 mmHg	≤ 15 mmHg	≤ 15 mmHg (may be mildly elevated in very severe cases but < 18 mmHg)	> 15 mmHg	> 15 mmHg
PVR	≤ 2 WU	> 2–3 WU, but usually < 5 WU	> 2 WU	> 3 WU	> 5 WU (may be lower after diuresis)	> 2 WU
RAP	± RAP increase	± RAP increase	normal	> 8 mmHg	> 14 mmHg	disproportionally elevated; RAP/PAWP > 0.5
CI	normal (≥ 2.5 L/min/m²)	normal or slightly decreased	normal (≥ 2.5 L/min/m²)	< 2.0 L/min/m²	< 2.0 L/min/m²	< 2.0 L/min/m²

Figure 4 — Acute Heart Failure: RHC Variables by Phenotype

Acute HF → RHC → three branches, with the LV branch splitting into two sub-phenotypes — a distinction the running text does not make:

Branch	Sub-phenotype	PAWP	CI	Systolic BP	Other	Profile
LV failure	Acute decompensation (LV dysfunction + systemic water retention)	> 15 mmHg	< 2.5 or ≥ 2.5 L/min/m²	normal to low	—	wet and warm OR dry and cold
LV failure	Acute pulmonary oedema (LV dysfunction + fluid redistribution to lungs)	*> 15 or ≤ 15 mmHg**	≥ 2.5 L/min/m²	> 90 mmHg	—	wet and warm
Isolated RV failure	—	< 18 mmHg	< 2.5 L/min/m²	< 90 mmHg	RAP > 8 mmHg	dry and cold OR wet and cold
Biventricular	—	> 15 mmHg	< 2.5 L/min/m²	< 90 mmHg	RAP > 8 mmHg; RAP:PAWP > 0.5	wet and cold

* May be normal with low CI.

Figure 5 — Shock: RHC Variables by Phenotype, Including SCAI Stages

The most granular shock table in the paper, and the source for the page's shock criteria. All values are measured by RHC.

Phenotype	RAP	PAWP	CI (L/min/m²)	MAP	SVRi	Profile	Lactate
Isolated right ventricular	> 14 mmHg (RAP:PAWP ≥ 0.8)	< 18 mmHg	< 2.2	< 60 mmHg	increased	—	—
Cardiogenic Stage A — At risk	≤ 10 mmHg	≤ 15 mmHg	≥ 2.5	≥ 60 mmHg	normal	warm and dry	normal
Stage B — Beginning	> 10 mmHg	> 15 mmHg	≥ 2.5	≥ 60 mmHg	normal	warm and wet	normal
Stage C — Classic	> 10 mmHg	> 15 mmHg	< 2.5	< 60 mmHg	increased	cold and wet	≥ 2 mmol/L
Stage D — Deteriorating	> 10 mmHg	> 15 mmHg	< 2.2	< 60 mmHg	decreased	cold and wet	≥ 2 mmol/L
Stage E — Extremis	> 10 mmHg	> 20 mmHg	< 1.8	< 60 mmHg	decreased	cold and wet	≥ 8 mmol/L
Vasodilatory (septic, allergic)	—	≤ 15 mmHg	≥ 2.5	—	decreased	warm and dry	—
Mixed shock	—	> 15 mmHg	< 2.2 or ≥ 2.2	—	decreased or normal	warm or cold and wet	—

Isolated RV shock additionally carries low RVSWI, and the RV column is distinguished by a RAP:PAWP ≥ 0.8 with a normal-to-low PAWP
The figure supplies the lactate thresholds for SCAI stages C–E (≥ 2, ≥ 2 and ≥ 8 mmol/L respectively) and the vasodilatory/mixed shock comparator columns, neither of which appears in the running text

Figure 6 — Management of PH in Adult HTX Candidates

Escalation ladder for a positive vasodilator challenge, with each step's failure triggering the next:

HTX candidate → RHC → potentially prohibitive PH? (sPAP ≥ 50 mmHg AND [TPG ≥ 15 mmHg or PVR ≥ 3 WU])

Acute vasodilator challenge (e.g. nitroprusside, milrinone) → if no change →
Diuresis + continuous vasoactive therapies + haemodynamic monitoring → if no change →
Trial of temporary mechanical circulatory support → if no change →
Durable LVAD (if appropriate) → if no change →
Palliative care

Any step that succeeds leads to list for transplant, gated on: TPG ≤ 12–15 mmHg and PVR ≤ 2.5–3 WU AND maintained systolic BP > 85 mmHg

LVAD-phase haemodynamic targets — three distinct phases:

Phase	Assessment	Target
Prior LVAD implantation	RV haemodynamics — 1–2 weeks prior in stable patients, or preoperatively in ICU	RAP ≤ 12–15 mmHg; RAP/PAWP < 0.6
After LVAD implantation	Invasive ramp test — optimise LVAD speed and medical therapy; detect malfunctions	RAP < 12 mmHg + PAWP < 18 mmHg
Prior LVAD explantation	Cardiac recovery — normal haemodynamics in a series of lowered or off-pump trials	CI > 2.6 L/min/m²; RAP < 10 mmHg; PAWP < 13 mmHg

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
Figures and graphical abstract survive only as images. The PDF typesets them as graphics with no selectable text, so their content is not searchable in raw/RHC-HF-EHJ-2025.md. All seven have been read and transcribed into the Data From Embedded Figures section above — but that transcription is manual, and carries a manual-transcription error risk that programmatic extraction would not. Several tables in that section also show values the running text states only partially or not at all (the six-phenotype chronic HF table, the two LV sub-branches of acute HF, the SCAI lactate thresholds, and the vasodilatory/mixed shock comparator columns), so the figures are load-bearing rather than illustrative

Key Concepts Mentioned

concepts/Right-Heart-Catheterization — central subject of the review
concepts/Pulmonary-Hypertension — classification framework; pre/post-capillary PH; PVR thresholds
entities/Heart-Failure — acute, chronic, advanced HF haemodynamic thresholds
entities/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
concepts/Pulmonary-Hypertension — PH classification; treatment implications
entities/CTEPH — mentioned in context of pre-capillary PH differential

Wiki Pages Updated

Original ingest (2026-04-19):

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/concepts/pulmonary-hypertension.md — updated (PAWP methodology and thresholds)

2026-10-16 — source-file repair and figure transcription (no --force re-conversion):

wiki/sources/rhc-hf-ehj-2025.md — new Data From Embedded Figures section; all 7 figures transcribed and embedded
wiki/concepts/SCAI-Shock-Classification.md — RHC-derived haemodynamic values per SCAI stage; the SVRi distinction between stages C and D; vasodilatory, mixed and isolated-RV shock comparator columns; source added
wiki/entities/HFpEF.md — new Latent HFpEF — Invasive Haemodynamic Provocation subsection; source added
wiki/sourceindex.md, wiki/wikiindex.md — rows refreshed

Why no re-conversion was performed. A full pymupdf4llm re-conversion was tested and rejected: the preview produced only 3 images from pages 1–2 against the 8 on disk, with zero name overlap — it would have orphaned and lost five data figures, including the chronic-HF classification table (Figure 3, page 8) and the figures on pages 12, 13 and 15. The existing file was repaired in place instead: the 8 image links were rewritten from C:/drgarywiki/raw/assets/… to /raw/assets/… (now portable and all resolving), and 25 ligature corruptions were corrected (confrm→confirm, fuid→fluid, flling→filling, insuffcient→insufficient, low-fow→low-flow, fuoroscopy→fluoroscopy, fbrillation→fibrillation, signifcantly→significantly, and others). Token count was unchanged at 13,173 through both repairs, confirming no content was lost. Backup: ~/cardiologywiki-backups/RHC-HF-EHJ-2025.md.pre-reconvert-20261016.