Methods to improve the yield of right heart catheterization in pulmonary hypertension

Right heart catheterization (RHC) is needed to diagnose pulmonary hypertension (PH). Traditional hemodynamic determinations may be insufficient to identify early stages of the disease and the mechanism of PH, confidently allocate patients to the pre- and/or postcapillary groups of the disease and guide certain treatment decisions (e.g. use of calcium channel blockers). In this review, we discuss the role of established (pulmonary vasodilatory, exercise and rapid fluid infusion challenges) and promising maneuvers (passive leg raising, intrathoracic pressure estimation, temporary exclusion of arteriovenous dialysis accesses and dobutamine infusion) that help interrogate the pulmonary vasculature during RHC, with a focus on describing rationale for use, indications, contraindications, protocols and implications of different responses.