A new state‑of‑the‑art review in the European Heart Journal says right‑heart catheterization (RHC)—a test that measures pressures inside the heart and lungs—remains essential for diagnosing problems and tailoring treatment across the spectrum of heart failure, from emergency care to transplant decisions. The review emphasizes that numbers from the catheter must be interpreted in the context of the whole patient to avoid misclassification. A graphical summary on page 1shows how RHC guides decisions in acute and chronic heart failure, cardiogenic shock, and in evaluating candidates for mechanical pumps and transplants.
What the test does
During RHC, a thin tube is threaded through a vein (usually in the neck) into the heart and lung arteries to record pressures, blood flow, and oxygen levels. It remains the gold standard for diagnosing and classifying pulmonary hypertension—a common and treatable complication of heart failure.
When it helps most
In the emergency setting, RHC can quickly distinguish left‑sided failure, right‑sided failure, or both, and guide choices about fluids, diuretics, blood‑pressure medicines, or advanced support. The flowchart on page 12 (Figure 4) shows the typical pressure patterns doctors look for. Observational studies link RHC use in cardiogenic shock with better in‑hospital outcomes and fewer complications; a randomized trial is underway.
Chronic and advanced heart failure
For longer‑term management, RHC data help confirm pulmonary hypertension (defined by mean lung‑artery pressure >20 mm Hg) and sort out whether the problem lies before or after the lungs—key to choosing the right therapy. Because diuretics can temporarily lower readings, the authors describe a “zone of uncertainty” (about 12–18 mm Hg for a key pressure called PAWP) and outline ways—like brief exercise, a small fluid challenge, or a passive‑leg raise—to unmask hidden disease.
Decisions about transplant or pumps
RHC is central to judging transplant readiness and left‑ventricular assist device (LVAD) candidacy. Very high lung pressures can make transplant too risky unless they drop to safer ranges during a brief vasodilator test; if not, optimizing medicines or using an LVAD may come first. The decision pathway on page 15 (Figure 6) and the table of thresholds summarize what clinicians aim for before listing, implanting a device, or—later—considering LVAD removal after recovery.
Safe—but technique matters
In experienced centers, serious complications are uncommon (~1.1%), and procedure‑related deaths are very rare (~0.055%). Still, accuracy depends on best practices: patient lying flat, ultrasound‑guided neck‑vein access, careful pressure “zeroing,” reading pressures at end‑exhalation, and making sure the catheter is correctly positioned. The troubleshooting table on page 5 (Table 1) details common pitfalls—like over‑ or under‑inflating the tiny balloon at the tip—that can skew results.
What’s next
Promising non‑invasive options are emerging—such as advanced cardiac MRI and echocardiographic measures—that estimate the same key pressures without a catheter, and new markers like pulmonary arterial compliance may flag trouble earlier. For now, RHC remains the benchmark that guides life‑changing decisions.
Source: Zeder K, Mak S, Galié N, Rosenkranz S, Maron BA. “Right heart catheterization in heart failure: indications, interpretation, and pitfalls.” European Heart Journal, 2025.
Editor’s note: This article is for information only and is not a substitute for professional medical advice.