Contemporary Evidence and Practice on Right Heart Catheterization in Patients with Acute or Chronic Heart Failure

Figures

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  Figure 1. Pressure curves in right heart catheterization. Normal pressure waveforms (a-wave—atrial contraction; c-wave—ventricular contraction; v-wave—atrial filling; x-wave—active atrial emptying; y-wave—passive atrial emptying) obtained in the right atrium (RA), right ventricle (RV), pulmonary artery (PA), and PCWP position with the typical tracings for each; mPAP—mean Pulmonary Artery Pressure; PCWP—Pulmonary Capillary Wedge Pressure; RAP—Right Atrial Pressure; RVDP—Right Ventricular Diastolic Pressure; RVSP—Right Ventricular Systolic Pressure.

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  Figure 2. HFA-PEFF stepwise diagnostic algorithm. STEP 1 stands for «Pretest assessment»; STEP 2 stands for «Echocardiography and natriuretic peptides score»; STEP 3 stands for «Functional testing in case of uncertainty»; STEP 4 stands for «Final etiology». AF—Atrial Fibrillation; BNP—Brain Natriuretic Peptide; CMR—Cardiac Magnetic Resonance; CO—Cardiac Output; CT—Computed Tomography; ECG—Electrocardiogram; GLS—Global Longitudinal Strain; HF—Heart Failure; HFpEF—Heart Failure with Preserved Ejection Fraction; LAVI—Left Atrial Volume Index; LVMI—Left Ventricular Mass Index; LVWT—Left Ventricular Wall Thickness; NT-proBNP—N-terminal Pro-Brain Natriuretic Peptide; PCWP—Pulmonary Capillary Wedge Pressure; PET—Positron Emission Tomography; RHC—Right Heart Catheterization; RWT—Relative Wall Thickness; TR—Tricuspid Regurgitation; TTE—Transthoracic Echocardiogram; 6MWT—6-Minute Walking Test. Adapted from Pieske B et al. [4].

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  Figure 3. Representation of pressure invasive exercise RHC. (A). The patient is usually in a supine position, exercising at a cycle ergometer. It is necessary for artery access, usually radial (red arrow), to assess systemic BP and SaO2, and central venous access, usually through a jugular vein (blue arrow), for the procedure itself. A mask (in green) is used to assess ventilatory parameters. (B). Workload scheme. The protocol starts with a cycle unloaded (0 watts) at rest (R) and then starts exercise with feet on a cycle ergometer (F) and increases of 20–25 Watts up to maximal exercise capacity every about 3 min. Measurements are practiced at every stage (X). (C). Representation of mPAP/CO and PCWP/CO slopes. AVO2—Arteriovenous Oxygen Difference; BP—Blood Pressure; CO—Cardiac Output; CO2—Carbon Dioxide; mPAP—Mean Pulmonary Artery Pressure; PA—Pulmonary Artery; PCWP—Pulmonary Capillary Wedge Pressure—SaO2—Oxygen Saturation; RER—Respiratory Exchange Rate; VE—Pulmonary Ventilation during exercise; VCO2—Carbon Dioxide Production; VO2—Venous Oxygen Saturation. Adapted from Hsu S. et al. [10].

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  Figure 4. Potential role of RHC to support diagnosis and decision-making in the context of advanced heart failure. Diagnostic algorithm of patients with AdHF candidates for heart transplant. With sPAP < 50 mm Hg, PVR < 3 WU, and transpulmonary gradient < 15 mmHg HTX is possible. sPAP ≥ 60 mm Hg, PVR ≥ 5 WU, and transpulmonary gradient ≥ 20 mm Hg are considered prohibitive for transplantation. In patients with 50 mmHg ≤ sPAP < 60 mm Hg, 3 WU ≤ PVR < 5 WU, and 15 mmHg ≤ transpulmonary gradient < 20 mmHg, a vasoreactivity test is indicated. If baseline PVR of ≥3 WU decreases after intravenous sodium nitroprusside to <3 WU, PH is not fixed, and the transplantation is not contraindicated. AdHF—Advanced Heart Failure; HTX—Heart Transplantation; PVR—Pulmonary Vascular Resistance; RHC—Right Heart Catheterization; sPAP—Systolic Pulmonary Artery Pressure; SSAP—Systemic Systolic Arterial Pressure; TPG—Transpulmonary Gradient; VAD—ventricular assist device; VBDT—VAD in Bridge to Decision Therapy; VBTT—VAD in Bridge to Transplantation Therapy; VDT—VAD in Destination Therapy; WU—Wood units. Adapted from Kittleson et al. [86].

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  Figure 5. Potential role of RHC to support diagnosis and decision-making in the context of cardiogenic shock. A team-based approach to the management of CS. The difference in the type of shock (LV, RV-LV, or RV shock) according to the hemodynamic parameters such as CPO, PAPi, PCWP, CVP, and mean arterial pressure can help the physicians in the choice of the device for ventricular support. BiV—Bi-Ventricular; ECMO—Extracorporeal Membrane Oxygenation; CPO—Cardiac Power Output; LV—Left Ventricular; MCS—Mechanical Circulatory Support; PAPi—Pulmonary Artery Pulsatility Index; PCWP—Pulmonary Capillary Wedge Pressure; pVAD—Percutaneous Ventricular Assist Device; RA—Right Atrial; RAP—Right Atrial Pressure; RHC—Right Heart Catheterization; RV—Right Ventricular; SBP—Systolic Blood Pressure. Adapted from Hsu S. et al. [10].