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The role of cardiac catheterization for children with congenital heart disease has changed dramatically over the past 10 years. Improved anatomic imaging of complex congenital heart disease with echocardiography, computerized tomography (CT), and magnetic resonance imaging (MRI) has made catheter-based angiography nearly obsolete for many common conditions. Today, most surgical patients with intracardiac lesions are diagnosed by echocardiography and undergo surgery without cardiac catheterization. MRI or CT has supplanted cardiac catheterization as the preoperative imaging modality for aortic arch abnormalities and coronary anomalies in many institutions, and MRI is the primary modality for measuring ventricular volumes and semilunar valve insufficiency. Transesophageal echocardiography supplements direct visualization during surgery and identifies residual abnormalities that can be promptly addressed intraoperatively, reducing the need for postoperative cardiac catheterization. Cardiac catheterization remains the primary test for evaluating complex physiology in children with abnormal pulmonary vascular resistance and reactivity, complex single ventricle anatomy, multiple obstructions in the right or left heart, or lesions of peripheral pulmonary arteries not seen well with other imaging modalities. Patients may need cardiac catheterization to assess residual defects soon after surgery when surface echo-Doppler studies may be less accurate.

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Cardiac catheterization can rarely lead to serious complications, including arrhythmias, arterial obstruction, reactions to contrast medium, hemorrhage, cardiac perforation, hypoxemic episodes, infections, and death. The mortality rate is 0.2%, with the highest risk occurring in premature infants, critically ill term neonates, and those patients undergoing complex interventional catheterization procedures. Older children at particular risk of death are those with a very high pulmonary vascular resistance and no means of shunting. Pulmonary hypertensive crises or vagal episodes may decrease systemic output and cause death during or soon after catheterization in such patients. About 3% of children may have significant but nonfatal complications. Radiation exposure is a concern, especially in children with complex disease requiring repeat catheterizations. However, the few longitudinal studies done in children after cardiac catheterization in childhood have not shown an increased rate of cancer in adult years.

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The most commonly used vessels for cardiac catheterization are the femoral, internal jugular, and subclavian veins and the femoral artery. The catheters are inserted percutaneously. Local infections and arterial complications are extremely rare, and the same vessels may be used repeatedly. In patients with congenital heart disease, the femoral approach often permits passage of a venous catheter into the left side of the heart through a patent foramen ovale or atrial septal defect, avoiding the use of the artery. Patients who have many repeat catheterizations may develop obstruction of the femoral or internal jugular veins, prohibiting their future use. If needed, vascular access can be safely obtained through percutaneous cannulation of the hepatic veins, called a “transhepatic approach” (eFig. 496.1). Some centers use carotid artery cut down with direct sheath placement and surgical repair for access for balloon valvuloplasty for critical aortic valve stenosis or for stent placement in the patent ductus arteriosus in a neonate with pulmonary atresia.

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