Right heart catheterisation: invasive diagnostics for precise assessment of cardiopulmonary function
Right heart catheterisation is an essential invasive diagnostic procedure in interventional cardiology for the detailed evaluation of right heart function and pulmonary haemodynamics using specialised balloon catheter systems. whereby this floating catheter technique enables atraumatic passage through right heart structures to peripheral pulmonary artery branches by means of balloon-controlled navigation. This established invasive right heart diagnostic procedure provides fundamental pathophysiological insights for the differential diagnosis of complex cardiovascular diseases through simultaneous pressure measurement, cardiac output determination and pulmonary capillary wedge pressure evaluation with high-precision quantitative functional analysis.
Procedural sequence of right heart catheterisation
Catheter insertion and navigation
Right heart catheterisation begins with sterile puncture of a central or peripheral vein under local anaesthesia, with the internal jugular vein or femoral vein being the preferred choice for optimal catheter guidance. The thin-walled balloon catheter is advanced through the right atrium and tricuspid valve into the right ventricle under continuous pressure monitoring, with the inflated balloon utilising the natural blood flow and “floating” atraumatically through the pulmonary valve ring into the pulmonary artery.
Floating technique and positioning: The characteristic floating property of the balloon catheter enables gentle navigation without active control into second- or third-degree pulmonary artery branches, where the inflated balloon is temporarily wedged in place to measure pulmonary capillary wedge pressure (PCWP). This balloon-controlled catheter positioning minimises the risk of arrhythmias and vascular injuries while providing optimal diagnostic information.
Haemodynamic measurement parameters and physiological evaluation
Wedge pressure analysis
Pulmonary capillary wedge pressure (PCWP) is a fundamental parameter in right heart catheterisation, reflecting the retrograde pressure in the pulmonary capillaries during temporary balloon occlusion of a pulmonary artery and thus indirectly reflecting the end-diastolic pressure in the left atrium. Normal PCWP values range between 5-12 mmHg, with elevated values >15 mmHg indicating left heart failure or pulmonary veno-occlusive disease.
Pressure gradient calculation: Right heart catheterisation allows precise determination of the transpulmonary gradient (TPG = mPAP – PCWP) to differentiate between pre- and post-capillary pulmonary hypertension, with TPG values >12 mmHg indicating a precapillary PH component and implying fundamental therapeutic consequences.
Sequential pressure recording
Systematic right heart catheterisation documents characteristic pressure curves during catheter passage:
Characteristic pressure profiles:
- Right atrium: Normal a- and v-waves with mean pressure 0-5 mmHg
- Right ventricle: Systolic 15-30 mmHg, end-diastolic 2-8 mmHg
- Pulmonary artery: Systolic 15-30 mmHg, diastolic 8-15 mmHg
- PCWP: Wedge position with characteristic a- and v-wave morphology
Thermodilution cardiac output measurement
Quantitative cardiac output determination
Right heart catheterisation integrates precise cardiac output measurement using thermodilution technology with specialised 4-lumen or 5-lumen catheter systems based on the Swan-Ganz principle. This quantitative CO analysis is performed by injecting defined volumes of cold saline solution through the proximal catheter lumen with simultaneous temperature recording at the distal thermistor for accurate cardiac output calculation.
Stress haemodynamics: Advanced right heart catheterisation protocols include stress tests using supine bicycle ergometry or passive leg elevation to evaluate haemodynamic reserve and detect latent left ventricular dysfunction in patients with exertional dyspnoea of unclear aetiology.
Specific indications for right heart catheterisation
Pulmonary hypertension evaluation
Right heart catheterisation is the gold standard for the confirmation and haemodynamic classification of pulmonary hypertension according to current ESC/ERS guidelines. This definitive PH diagnosis quantifies the mean pulmonary artery pressure (mPAP ≥20 mmHg), differentiates between pre- and post-capillary PH aetiology and determines the severity assessment for therapeutic decision-making.
Vasoactivity testing: Specialised right heart catheterisation protocols integrate acute vasoreactivity tests with inhaled nitric oxide (NO), iloprost or intravenous adenosine to identify patients with a potential response to calcium channel blocker therapy in idiopathic pulmonary arterial hypertension.
Heart failure diagnostics
In symptomatic heart failure, right heart catheterisation enables objective quantification of biventricular function, filling pressures and haemodynamic performance reserve for differentiated therapy selection between drug optimisation, device therapy or advanced heart failure strategies. This comprehensive HF evaluation determines prognostically relevant parameters such as cardiac index, pulmonary capillary wedge pressure and right ventricular filling pressure.
Shunt detection and congenital heart defect diagnostics
Oximetric shunt quantification
Right heart catheterisation enables precise detection and quantification of intracardiac shunts through sequential blood gas analysis and oxygen saturation measurement during systematic catheter passage. This oximetry-based shunt analysis identifies significant left-to-right shunts in congenital heart defects and quantifies the shunt ratio (Qp:Qs) for surgical indication.
EMAH follow-up: In adults with congenital heart defects (EMAH), right heart catheterisation provides fundamental haemodynamic parameters for assessing postoperative residuals, progression of acquired complications and evaluation of complex reoperation indications in Fontan circulation or other palliative corrections.
Complication management and safety aspects
Procedural risk minimisation
Right heart catheterisation has a more favourable safety profile compared to left heart catheterisation, with major complication rates <1% due to balloon-guided navigation and avoidance of active catheter manipulation. Potential complications include transient arrhythmias, pulmonary artery injuries due to overwedging, and rare catheter entanglements in complex anatomy.
Overwedging prevention: Critical safety aspects of right heart catheterisation include avoiding overwedging through controlled balloon inflation and continuous pressure curve monitoring, whereby falsely high PCWP readings due to catheter impaction against the vessel wall must be prevented.
Advanced catheter technologies
Multi-lumen catheter systems
Modern right heart catheterisation systems use 4-lumen or 5-lumen thermodilution balloon catheters with separate lumens for pressure measurement, thermodilution, balloon inflation and additional infusion or drug administration. These advanced multi-lumen platforms optimise diagnostic yield during simultaneous therapeutic interventions during the examination.
Continuous monitoring catheters: Specialised PA catheter systems for long-term monitoring integrate continuous mixed venous oxygen saturation (SvO2) measurement and real-time cardiac output monitoring for intensive care patients with haemodynamic instability or after cardiac surgery.
Evidence-based indications and guidelines
Guideline-compliant application
Current recommendations from the European Society of Cardiology define specific Class I indications for right heart catheterisation for the diagnosis of pulmonary hypertension, heart transplant evaluation and haemodynamically guided heart failure therapy in cases of unclear aetiology or refractory disease progression. This evidence-based indication optimises diagnostic yield with minimal procedural risks.
Integration of high-precision haemodynamic monitoring systems
The diagnostic precision of right heart catheterisation requires integrated haemodynamic monitoring systems with high-resolution pressure signal acquisition, precise thermodilution calculation and advanced physiological parameter analysis for complex cardiopulmonary pathologies. Modern right heart catheterisation laboratories with intelligent measurement system integrations enable the successful performance of demanding invasive right heart diagnostics with optimal measurement accuracy and sustainable diagnostic findings for evidence-based therapy optimisation in the most complex cardiovascular diseases through exceptional pressure curve visualisation, real-time haemodynamic assessment and automated calculation algorithms.
Note: This information is intended solely for medical training purposes and does not replace specialist advice from qualified invasive cardiologists. Performing right heart catheterisation requires specialised training and appropriate certification in invasive cardiology.