Major statements regarding exercise right heart catheterisation

Essential measurements and calculations at each exercise levelMeasurement of PAPm, PAWP and CO
Calculation of TPR (PAPm/CO) and PVR ((PAPm − PAWP)/CO) as well as the PAPm/CO slope
Supplementary measurementsAssessment of RAP during increasing exercise levels
Systemic and pulmonary arterial blood gas analysis at least at peak exercise
Zero reference levelAt the left atrial level for both rest and exercise
Supine position: midthoracic level at the insertion of the 4th rib to the sternum
Non-supine position: intersection of the frontal plane at the midthoracic level, the transverse plane at the level of fourth anterior intercostal space and the midsagittal plane
Dealing with respiratory swingsDuring exercise: averaging pulmonary pressure values over several respiratory cycles
Comparing exercise and resting haemodynamics: all conditions (body position, zero level and respiratory averaging) must be exactly the same at rest and during exercise
Exercise duration and performanceIncremental exercise tests (step or ramp protocol) with repeated haemodynamic measurements may provide most clinical information on the pulmonary circulation
For reaching a steady state for oxygen uptake on a given exercise level (step protocol), generally 3–5 min are needed; however, for practical reasons, shorter time intervals may be chosen (e.g. 2-min steps aiming for a duration of the exercise time of ∼10 min)
Prolonged exercise tests of the pulmonary circulation have not been evaluated for the detection of early pulmonary vascular disease or left heart conditions
Isometric exercise has little or no effect on CO, and may considerably change pleural pressure and systemic vascular pressure and resistance and is not suitable to challenge the pulmonary circulation
SafetyRisk/benefit ratio of the assessment of pulmonary haemodynamics during exercise is unfavourable in patients without thorough resting haemodynamic examinations, patients with unstable disease or patients with decompensated right heart failure
From an ethical point of view, it may be difficult to justify invasive exercise examinations in healthy controls or in patients who did not undergo a thorough diagnostic work-up at rest

PAPm: mean pulmonary arterial pressure; PAWP: pulmonary arterial wedge pressure; CO: cardiac output; TPR: total pulmonary resistance; PVR: pulmonary vascular resistance; RAP: right atrial pressure.