Right Heart Catheterization: Best Practices and Specific Considerations

Right heart catheterization (RHC) remains the gold standard for the invasive assessment of cardiovascular hemodynamics, enabling direct measurement of right atrial, right ventricular, pulmonary artery, and pulmonary arterial wedge pressures, as well as cardiac output and mixed venous oxygen saturation. Although earlier randomized trials questioned the routine use of pulmonary artery catheters in critically ill patients, RHC continues to play a crucial role in the diagnosis and management of pulmonary hypertension, advanced heart failure, cardiogenic shock, and complex structural or valvular heart disease. The clinical value of RHC, however, depends not only on performing the procedure but also on obtaining accurate and physiologically meaningful measurements. This review summarizes contemporary best practices for performing RHC in routine clinical practice. Key procedural considerations include defining the clinical objective prior to catheterization, selecting appropriate vascular access, ensuring correct transducer leveling and signal fidelity, and accounting for respiratory variation and hemodynamic conditions during pressure acquisition. The review also discusses methodological aspects of measuring pulmonary arterial wedge pressure, cardiac output, and intracardiac shunts, and highlights common technical pitfalls that may lead to misinterpretation of hemodynamic data. In addition, the evolving role of RHC in clinical decision-making is reviewed, including its application in the hemodynamic classification of pulmonary hypertension, vasoreactivity testing, exercise hemodynamics for suspected heart failure with preserved ejection fraction, and differentiation of constrictive pericarditis from restrictive cardiomyopathy. Standardized acquisition and careful interpretation of hemodynamic data are essential to maximize the diagnostic and therapeutic value of RHC in contemporary cardiovascular practice.