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
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
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
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