The added value of right atrial assessment for the echocardiographic estimation of elevated central venous pressure

Introduction

Current echocardiographic guidelines for estimating central venous pressure (CVP) rely primarily on inferior vena cava (IVC) diameter and inspiratory collapse. However, this approach often lacks accuracy in several clinical scenarios. Anatomical and functional assessment of the right atrium (RA), including emerging deformation parameters like RA strain, may provide a more comprehensive non-invasive evaluation of right-sided hemodynamics.

Objectives

To assess the diagnostic value of right-sided echocardiographic variables for the non-invasive identification of elevated hemodynamic CVP.

Methods

In this prospective, single-center study, 155 consecutive patients undergoing clinically indicated right heart catheterization (RHC) were enrolled between November 2023 and December 2025. Transthoracic echocardiography was performed within 12 hours prior to RHC. For reliable strain analysis, patients with atrial arrhythmias (n=33), pacemaker rhythm (n=7), or severe tricuspid regurgitation (n=6) were excluded, resulting in a final cohort of 109 patients. Elevated CVP was defined as ≥10 mmHg on RHC. IVC-based CVP was estimated according to current guidelines (3, 8, or 15 mmHg). RA strain was analysed using speckle-tracking echocardiography (reservoir, conduit and booster pump phases).

Results

Baseline clinical characteristics, clinical indications, invasive hemodynamics, and echocardiographic data are summarized in Figure 1. RA strain analysis was feasible in 86% of the cohort. Invasive CVP correlated significantly with RA area (r=0.46, p<0.001), RA reservoir strain (RArs; r=–0.31, p=0.003) and IVC-based estimation (r=0.32, p=0.001). ROC analysis (figure 2) showed that RA area (AUC 0.82; p<0.001) and RArs (AUC 0.69; p=0.006) were superior discriminators for CVP ≥10 mmHg compared with IVC assessment (AUC 0.61; p=0.108).

Optimal cut-off values were RA area ≥17.3cm2 (J=0.47; sensitivity 92%, specificity 55%) and RArs ≤24.5% (J=0.31; sensitivity 63%, specificity 68%). In multivariable logistic regression, both RA area (OR 11; 95% CI 2.2-54.5; p=0.003) and RArs (OR 3.1; 95% CI 1.02-9.9; p=0.046) remained independent predictors of elevated CVP, whereas IVC assessment did not (p=0.93). A combined model integrating RA area and RArs achieved the highest diagnostic performance (AUC 0.84; 95%CI 0.75–0.93; p<0.001).

Conclusions

In our cohort, RA anatomical (area) and deformation parameters (reservoir strain) provide a significantly more accurate estimation of invasively measured CVP than the guideline-recommended IVC-based approach. Their integration into standard echocardiographic assessment may improve the non-invasive evaluation of right-sided hemodynamic in clinical practice.Figure 1.Baseline tableFor image description, please refer to the figure legend and surrounding text.Figure 2.ROC curvesFor image description, please refer to the figure legend and surrounding text.