Guidelines for Right‑Heart Catheterization with a Swan‑Ganz Pulmonary Artery Catheter

1. Catheter Insertion and Advancement

Insert the catheter through a central vein (e.g., internal jugular, subclavian, or femoral) and advance it with the balloon deflated until the tip reaches the right atrium. European Respiratory Society recommendation. 1
Inflate the balloon in the right atrium, then advance the catheter sequentially through the right ventricle into the pulmonary artery using the blood flow to guide the balloon‑tipped catheter forward. European Respiratory Society recommendation. 1
Avoid repeated balloon inflations and deflations in distal pulmonary arteries because this practice increases the risk of pulmonary artery rupture. European Respiratory Society safety warning. 1

Zero the external pressure transducer at the mid‑thoracic level in a supine patient (midway between the anterior sternum and the bed surface), which approximates the left atrial level. European Respiratory Society technical guideline. 2
Record all pressure measurements at end‑expiration to minimize respiratory artefact; alternatively, average pressures over several respiratory cycles when dynamic hyperinflation is absent. European Respiratory Society recommendation. 2
Normal pressure ranges (based on healthy adult populations):
- Right‑atrial pressure: 2–8 mm Hg. American College of Cardiology reference. 3
- Right‑ventricular pressure: systolic 15–25 mm Hg, diastolic 0–8 mm Hg. American College of Cardiology reference. 3
- Pulmonary‑artery systolic pressure: 15–25 mm Hg. American College of Cardiology reference. 3
- Pulmonary‑artery diastolic pressure: 8–15 mm Hg. American College of Cardiology reference. 3
Pulmonary‑artery wedge pressure (PAWP) is obtained with the balloon inflated in a wedge position and reflects left‑atrial pressure. European Respiratory Society guideline. 2

Cardiac output should be measured by thermodilution (inject cold saline in triplicate) or, when thermodilution is unreliable, by the direct Fick method. European Respiratory Society recommendation; thermodilution preferred for reliability even with low output or severe tricuspid regurgitation. 2
Obtain oxygen‑saturation samples from the superior vena cava, inferior vena cava, pulmonary artery, and systemic artery to construct stepwise saturation profiles. European Respiratory Society protocol. 2
Pulmonary vascular resistance (PVR) is calculated as (mean PA pressure − PAWP) ÷ cardiac output. American College of Cardiology formula; also endorsed by Chest society. 3
Mixed‑venous oxygen saturation is derived from the pulmonary‑artery blood sample. American College of Cardiology and Chest guidance. 3
Confirm true wedge position by obtaining a blood sample with the balloon inflated; the sample should have an oxygen saturation identical to systemic arterial blood. European Respiratory Society verification step. 2
Record PAWP as the mean of three consecutive measurements to improve accuracy. European Respiratory Society recommendation. 2
Use high‑fidelity printed waveforms rather than small moving traces on a monitor for optimal waveform interpretation. European Respiratory Society technical tip. 2

Perform stepwise oxygen‑saturation assessment in every patient with pulmonary‑arterial O₂ saturation > 75 % or when a left‑to‑right shunt is suspected. European Respiratory Society screening guideline. 2
In patients with intracardiac shunts, thermodilution may be inaccurate due to early recirculation of the injectate; the direct Fick method should be used instead. European Respiratory Society recommendation. 2
Spontaneous variability in pulmonary‑artery pressure can reach 20 mm Hg within an individual, with a mean coefficient of variability of 8 %. Chest observation on measurement variability. 4
Hemodynamic measurements obtained during catheterization reflect resting supine conditions only and may not represent pressures during upright posture, activity, or sleep. Chest limitation note. 4

When performed at expert centers, right‑heart catheterization has a serious‑event rate of approximately 1.1 % and a mortality rate of 0.055 %. European Respiratory Society safety data. 2
The most frequent complications are venous‑access related (hematoma, pneumothorax), followed by arrhythmias and hypotensive episodes. American College of Cardiology complication profile. 3
Because of its technical complexity and the need for meticulous attention to detail, the procedure should be limited to expert centers. European Respiratory Society institutional recommendation. 2

The American Thoracic Society and other medical organizations recommend right-heart catheterization as the gold standard for measuring mean pulmonary artery pressure, which is required to confirm the presence of pulmonary hypertension, establish specific diagnosis, and determine disease severity 5, 6
Right-heart catheterization provides direct and accurate measurements of mean pulmonary artery pressure, right atrial pressure, pulmonary capillary wedge pressure, pulmonary blood flow, and mixed venous oxygen saturation, as well as calculation of pulmonary vascular resistance 5, 6
The procedure also allows for exclusion of other etiologies such as intracardiac or extracardiac shunts and left-heart disease, and assessment of right-heart dysfunction through measurement of right atrial pressure and cardiac output 5, 6

The European Respiratory Society notes that while Doppler echocardiography can provide a proxy measurement of pulmonary hemodynamics by estimating right ventricular pressure, it is not a substitute for the more accurate values obtained by right-heart catheterization 5, 6
Estimated pulmonary artery systolic pressure (ePASP) can be calculated by measuring the velocity of the tricuspid regurgitation jet using the modified Bernoulli equation, and adding estimated right atrial pressure based on inferior vena cava size and collapsibility 7

The American College of Cardiology recommends right-heart catheterization in patients with suspected pulmonary hypertension to confirm diagnosis and guide therapy, particularly in those with elevated estimated PASP > 30 mm Hg on echocardiography 6, 7
In patients with sickle cell disease, catheterization decisions should be based on echocardiograms obtained at steady state, with additional consideration of NT-BNP and 6-minute walk distance 8
Symptomatic patients with dyspnea, fatigue, chest pain, syncope, or signs of right heart failure require catheterization regardless of echocardiographic findings 8

Pulmonary hypertension is defined hemodynamically by right-heart catheterization as mean pulmonary artery pressure > 20 mm Hg, with additional criteria for pulmonary arterial hypertension including pulmonary artery wedge pressure ≤ 15 mm Hg and pulmonary vascular resistance ≥ 3 Wood units 8