delivery of contrast at high pressures without catheter recoil The cardiovascular anatomy including vessel diameter, and ventricular function can be quantitated to obtain anatomic and function data Accurate calibration is routinely available through automated calibration references with the patient positioned at isocenter on the table The catheter size (French size of the catheter divided by 3 [i.e., 6 Fr catheter divided by 3 = 2 mm for calibration use]) may be used as a reference for calibration; however, calibration errors can occur if the structure is larger than the catheter itself When one describes imaging angles, it is common to refer to the image intensifier or flat panel detector as the “anteroposterior camera.” Technically, the camera or x-ray tube is posterior to the patient on the table and the beam goes toward the image intensifier that is anterior to the patient; thus it is actually the “posteroanterior camera.” Standard angiography projections are outlined in Table 17.1, contrast dosage recommendations by anatomic location are outlined in Table 17.2, and angiography angles by anatomic location are outlined in Table 17.3 Table 17.1 Fluoroscopy Camera Angles for the Frontal Posteroanterior and Lateral View FRONTAL CAMERA STANDARD ANGLES FOR CONGENITAL CARDIAC CATHETERIZATION Direct PA 0 Degrees “Sitting up” (cranial) 0 Degrees frontal/+20–40 degrees cranial “Laid back” (caudal) 0 Degrees frontal/30–40 degrees caudal RAO 20–40 Degrees RAO LATERAL CAMERA STANDARD ANGLES FOR CONGENITAL CARDIAC CATHETERIZATION Direct lateral projection 90 Degrees LAO 20–60 Degrees LAO Long axial oblique 70 Degrees lateral/30 degrees cranial Hepatoclavicular view 45 Degrees lateral/45 degrees cranial Aortic outflow tract view 100 Degrees lateral/30 degrees caudal LAO, Left anterior oblique; PA, posteroanterior; RAO, right anterior oblique Table 17.2 Contrast Dosage Recommendations Injection Site Normal ventricles Enlarged ventricles Dose (mL/kg) 1.25–1.5 1.5–2.0 Injection Rate (mL/kg/s) 0.5–1.0 1.0–2.0 Normal flow aorta Increased flow aorta Pulmonary arteries Pulmonary wedge Pulmonary vein wedge 0.8–1.0 1.5–2.0 0.75–1.0 0.5–1.0 0.3–0.6 1.0–1.5 1.5–3.0 1.0 0.25 mL/s 0.5 mL/s Table 17.3 Fluoroscopy Camera Angles by Anatomic Location Anatomic Frontal (PA) Location (°) Systemic veins Right atrium RV RAO 20–30 RV outflow Cranial 30–40 pulmonary valve Pulmonary Cranial 30–40 arteries Sano shunt Steep caudal Pulmonary veins Left atrium Left ventricle RAO 25–30 Aortic valve RAO 25–30 Ascending aorta RAO 25–30 Aortic arch LAO 40–50 Caudal 20–40 BT shunt Steep caudal angulation PDA RAO 40 Caudal 30 AP collaterals Renal arteries Femoral arteries Lateral(°) Additional Considerations 90 90 90 90 SVC/Glenn anastomosis may require PA—“sitting up” 90 PA—“sitting up”—cranial 90 90 90 90 90 90 90 PA—“laid back” caudal 90 PA—“laid back” caudal 90 Ductus in lateral over the trachea 90 Best view to assess total flow to lungs related to AP collaterals, and anatomy of the renal or ileofemoral vessels PA—RAO PA—“sitting up”—cranial PA—RAO PA—RAO PA—RAO PA—“laid back” with LAO AP, Anteroposterior; LAO, left anterior oblique; PA, posteroanterior; PDA, patent ductus arteriosus; RAO, right anterior oblique; RV, right ventricle; SVC, superior vena cava Diagnostic Cardiac Catheterization: Anatomic Approach Systemic Veins Femoral Vein The standard right heart catheterization is performed from the femoral veins Access is obtained using the Seldinger technique and/or with vascular ultrasound guidance Femoral venous occlusion should be documented only in the chart if there is angiographic or ultrasound evidence of occlusion Revascularization of the occluded femoral veins can be accomplished when necessary but requires clinical experience with this technique Inferior Vena Cava The IVC is accessed from the femoral veins In general, hemodynamic data are important from the IVC to determine the mixed venous saturation and assess venous pressures in the presence of Fontan pathway anastomosis, transposition of the great vessels inferior baffle, or history of venous thrombosis The IVC can be interrupted in the presence of heterotaxy of the polysplenia type proceeding as an azygous continuation behind the heart to the superior vena cava (SVC) During the diagnostic catheterization this is obvious when the catheter is behind rather than within the heart in the lateral projection If diagnostic evaluation is necessary across an IVC filter, distal IVC angiography can be performed and the filter crossed with a hemodynamic catheter to perform the right heart evaluation Hepatic Veins Information is usually not necessary except in patients with concern for portal hypertension such as Fontan patients Then the hepatic vein mean pressure and mean hepatic vein wedge pressure are used to calculate the transhepatic gradient The other time the hepatic veins are important is when the patient is undergoing a pre-Fontan evaluation and the location of the hepatic vein in relation to the IVC is important in preparation for the Fontan operation Heterotaxy patients can, in 25% of the cases, have ipsilateral hepatic veins The hepatic veins are