Right heart failure – hemodynamic profile

Right heart failure describes the inability of the right ventricle to deliver adequate cardiac output against the pulmonary afterload. Hemodynamically there is a markedly raised central venous pressure above 15 mmHg together with a low cardiac index. Two derived measures are particularly informative: a CVP to PCWP ratio above 0.86 shows that right-sided filling pressure is disproportionately high relative to the left, and a pulmonary artery pulsatility index below 0.9 describes a right ventricle no longer generating adequate pressure amplitude. Both can be calculated from standard right heart catheter measurements.

For educational use only. Not for clinical use.

Hemodynamic profile

ParameterDirectionTypicalNormal range
ZVD↑> 15 mmHg2-6
PCWP→CVP/PCWP > 0.866-15
PAPI↓< 0.9> 0.9
CI↓reduced2.5-4.0
SvO2↓reduced65-75

Differentiation

Differentiate fromDiscriminating parameterExplanation
Obstructive shockPCWPBoth show a high CVP with a low cardiac index. Obstructive shock involves an acute mechanical obstacle, right heart failure a contractility problem of the right ventricle — and in tamponade the diastolic pressures also equalise.
Cardiogenic shockPCWPIn left-sided cardiogenic shock PCWP clearly exceeds CVP. A CVP/PCWP ratio above 0.86 instead shifts the picture towards the right ventricle.

Causes

  • Right ventricular myocardial infarction
  • Acute pulmonary embolism with right heart strain
  • Advanced pulmonary hypertension of any cause
  • Right heart failure after left ventricular assist device implantation
  • Arrhythmogenic right ventricular cardiomyopathy
  • Severe tricuspid regurgitation

Clinical context

Clinically, distended neck veins, hepatomegaly, ascites and peripheral oedema dominate while the lungs often remain clear on auscultation — a contrast that points to the right heart. PAPI is best established in predicting right heart failure after left ventricular assist device implantation, where values below 0.9 indicate substantially increased risk. Serial assessment matters: an isolated raised CVP may simply reflect volume overload, and only the combination of low cardiac index, high CVP/PCWP ratio and low PAPI makes the picture unambiguous.

Frequently asked questions

Which values indicate right heart failure?
A CVP above 15 mmHg with a low cardiac index, supported by a CVP/PCWP ratio above 0.86 and a PAPI below 0.9. Only the combination of these values is informative.
What is PAPI and how is it calculated?
The pulmonary artery pulsatility index is the pulmonary artery pulse pressure divided by central venous pressure, that is (PA systolic − PA diastolic) over CVP. It describes the pressure amplitude the right ventricle still generates at a given filling pressure.
Why does the CVP to PCWP ratio matter?
It relates right-sided filling pressure to left-sided. In left-sided failure PCWP clearly exceeds CVP; when CVP approaches or exceeds PCWP, the problem has shifted to the right side.
How do you distinguish right heart failure from obstructive shock?
Both show a high CVP with a low cardiac index. Obstructive shock involves an acute mechanical obstacle, and tamponade additionally equalises all diastolic pressures; right heart failure by contrast is a contractility problem of the right ventricle.
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