The following are key points to remember from a state-of-the-art review on practical guidance for hemodynamic assessment by right heart catheterization (RHC) in the management of heart failure (HF):

1. For patients with HF, assessment of invasive hemodynamics with RHC may provide useful information, especially in the setting of advanced HF, refractory HF symptoms, or unclear etiology of symptoms.
2. RHC can provide information regarding both left- and right-sided cardiac filling pressure, cardiac output, pulmonary artery pressure, pulmonary and systemic vascular resistance, and exercise-induced changes. While some of this information can be inferred with physical exam, laboratory testing, and noninvasive imaging, there are known diagnostic limitations to these other approaches.
3. To limit sources of error when obtaining and interpreting RHC hemodynamic data, it is important to properly zero pressure transducers, record pressure measurements at end-expiration during normal respiration, account for variations in pressure tracings for various conditions (e.g., constriction/restriction, intracardiac shunts, valve regurgitation, arrhythmias, morbid obesity, significant lung disease), and use directly measured whole body oxygen consumption (VO₂) when possible for Fick cardiac output calculations (thermodilution generally preferred over indirect/estimated Fick if direct Fick cannot be obtained).
4. For cardiogenic shock, invasive hemodynamic data are useful for establishing a diagnosis, identifying left and/or right ventricular failure, differentiating from other forms of circulatory shock, stratifying risk based on hemodynamic parameters, escalating or de-escalating pharmacologic and mechanical circulatory device therapies, and determining eligibility for advanced HF therapies.
5. While routine use of a RHC in patients with HF with reduced ejection fraction (HFrEF) is not recommended, it may be helpful in cases of uncertain volume status, inadequate response to diuretic therapy, or uncertain cause of worsening renal function.
6. In HF with preserved EF (HFpEF), establishing a diagnosis can be challenging given the heterogenous nature of this condition, especially when patients appear clinically euvolemic and have normal natriuretic peptide levels. Invasive hemodynamic exercise stress testing can provide diagnostic and prognostic information in this population.
7. Elevated pulmonary artery pressures, or pulmonary hypertension (PH), commonly occurs in patients with HF due to elevated left-sided filling pressures. RHC is not always necessary when PH is suspected on echocardiogram but can be helpful when PH appears out-of-proportion to the degree of HF to better establish the PH phenotype and guide management.
8. For durable left ventricular assist devices (LVADs), RHC is commonly used pre-device implant to assess risk for right HF with device therapy, perioperatively to optimize hemodynamics and end-organ function going into surgery, and postoperatively to optimize LVAD pump speed, assess for device-related complications, and assess for myocardial recovery.
9. In the evaluation for possible heart transplantation, RHC data are important for defining the severity of HF and ruling out significant pulmonary vascular disease. Hemodynamic data are also required for many of the listing criteria and need to be updated periodically based on priority of the listing status.
10. High output HF is uncommon but is diagnosed when clinical HF is present with a cardiac index >4.0 L/min/m². Causes of high output HF include obesity, liver disease, and arteriovenous fistulas. In the case of fistulas, hemodynamic data can be collected at baseline and with fistula compression to better understand the pathophysiology.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Heart Failure, Hemodynamics

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