298 SECTION IV Pediatric Critical Care Cardiovascular the world, with continued technological advancements aiming to broaden its applicability to a larger number of patients There are currently two de[.]
298 S E C T I O N I V Pediatric Critical Care: Cardiovascular the world, with continued technological advancements aiming to broaden its applicability to a larger number of patients There are currently two devices approved by the US Food and Drug Administration for TPVR: the Melody valve (Medtronic) and the SAPIEN XT valve (Edwards Lifesciences) The Melody valve is a bovine jugular venous valve sewn into a platinum iridium stent The SAPIEN XT valve consists of bovine pericardial leaflets sewn into a stainless-steel stent Current indications for TPVR are limited to its use within a preexisting right ventricular to PA conduits; however, off-label use of TPVR for patients with native right ventricular outflow tracts (RVOT), most commonly in patients with tetralogy of Fallot after transannular patch repair, can be performed when feasible TPVR requires placement of a large (16–22 Fr) venous sheath and a delivery system that can be difficult to maneuver into position from the percutaneous approach A hybrid perventricular approach may be necessary in younger patients and/or patients with complex anatomy Although the recovery is quick compared with surgical pulmonary valve replacement, children will often require postprocedural monitoring in the ICU overnight The most severe procedural complications include conduit tear or rupture during balloon and/or stent angioplasty of the RVOT and coronary artery compression from the RVOT stent or transcatheter valve Coronary compression testing with a balloon is necessary before proceeding with TPVR to avoid this complication; patients with evidence of coronary compression during balloon inflation across the RVOT will require surgical management.53 Conduit tears can usually be managed in the catheterization laboratory with placement of a covered stent, but emergent surgical management is occasionally required Postprocedural complications of TPVR include endocarditis and stent fractures leading to valve dysfunction that sometimes requires surgical or catheter-based reintervention A high index of suspicion is necessary for diagnosing endocarditis of the transcatheter pulmonary valve in patients who develop unexpected or acute valve dysfunction, as patients not present with the typical features seen in left-sided valve endocarditis Because the RVOT is often difficult to visualize with either transthoracic or transesophageal echocardiography, intracardiac echocardiography may be necessary to visualize or rule out a vegetation.54,55 Risks and Complications The relative benefits of cardiac catheterization must be balanced against the procedural risks associated with these procedures Table 30.3 lists the specific problems that can occur during various transcatheter procedures Placement of catheters in and through the heart increases the risk for dysrhythmias, perforation of the myocardium, damage to valve leaflets and chordae, cerebral vascular accidents, clot formation, and air embolism Use of radiopaque contrast material may cause an acute allergic reaction (rare in children with the use of nonionic contrast media), pulmonary hypertension, acute kidney injury, and myocardial depression Blood loss can occur due to traumatic injury or as a result of more insidious losses, such as access site bleeding or intraprocedural blood sampling Device-related complications, such as embolization or erosion, are also a possibility Preprocedural Risk Stratification The Catheterization RIsk Score for Pediatrics (CRISP score) was developed56 and subsequently refined and validated57 as a preprocedural risk score to predict the likelihood of a procedure-related serious adverse event The risk score is available as an online calculator (http://www.pmidcalc.org/?sid526527119&newtest5Y) and assigns points based on timing of the procedure (elective, emergent, or postoperative), patient age/weight, need for inotropic support, presence of systemic illness, physiologic category, precatheterization diagnosis, and procedural risk category In the multicenter analysis (n 26 centers, 30,000 procedures) used to develop and validate the CRISP score, serious adverse events occurred in 4.3% of all catheterization cases but in 12.7% of cases with a CRISP score of 10 to 14 and in 27.3% of cases with a CRISP score of 15 or greater The most common serious adverse events included vascular, cardiac, or pulmonary trauma; development of new hemodynamic instability requiring escalated support; and development of a new arrhythmia requiring intervention In broad terms, the most common risk factors for adverse events in children undergoing cardiac catheterization include procedural complexity, younger age, presence of comorbid conditions (hemodynamic vulnerability, respiratory failure, systemic illness, and so on), and timing of the procedure (e.g., elective vs emergent).56–59 These factors should be considered in evaluating the risk-benefit profile of catheterization for a patient in the critical care setting Cardiac Catheterization and Extracorporeal Membrane Oxygenation Children requiring mechanical circulatory support, including ECMO, represent some of the highest-risk patients Transport to and from the catheterization laboratory increases risk of infection and/or hardware dislodgement, bleeding risks are increased due to systemic anticoagulation, and thrombosis risk is increased when anticoagulation is held to facilitate obtaining vascular access There is also risk for renal injury from nephrotoxic contrast agents, and there are obvious risks associated with performing interventions in such a vulnerable population Moreover, the hemodynamic data are typically limited, as they may reflect mechanical support rather than the patient’s intrinsic cardiopulmonary physiology Despite these concerns and limitations, cardiac catheterization is often important in patients who require mechanical circulatory support,60 and a number of published series have described the feasibility and utility of cardiac catheterization in this patient population.61,62 It is well documented that unrecognized anatomic lesions can contribute to failure to wean from mechanical circulatory support, and the diagnostic capabilities of other imaging modalities (e.g., echocardiography) may be limited by the indwelling hardware Specific indications for catheterization may include unexplained and refractory low cardiac output state, unexplained cardiac arrest, severe cyanosis, and refractory arrhythmias.63,64 In patients recovering from heart surgery, guidelines from the American Heart Association state that “Cardiac catheterization with potential for intervention is indicated early in the postoperative period in any patient who requires mechanical cardiopulmonary support without a clear cause (Class I, Level of Evidence: B).”7 Endomyocardial biopsy may be considered in patients with fulminant myocarditis to help determine whether recovery can be expected (i.e., in cases of more acute myocarditis) or whether mechanical circulatory support is necessary as a bridge to heart transplantation In patients on ECMO with left heart distension, left heart decompression via atrial septostomy may be indicated CHAPTER 30 Diagnostic and Therapeutic Cardiac Catheterization TABLE 30.3 299 Potential Complications in the Catheterization Laboratory Procedure Representative Lesion Complications Hemodynamic evaluation Congenital heart disease Pulmonary hypertension Postoperative course; progress not as expected, persistent low cardiac output state, inability to wean from mechanical ventilation, persistent chylous effusions; evaluate residual intracardiac shunt or outflow tract obstruction Blood loss requiring transfusion Air embolism Vascular access; trauma, dissection, occlusion, perforation Myocardial perforation and tamponade Arrhythmias; ventricular and supraventricular tachycardia, ventricular fibrillation, complete heart block Coil embolization Aortopulmonary collaterals Systemic-pulmonary shunts Fevers Excessive hypoxemia Systemic embolization Transcatheter device closure Patent ductus arteriosus Atrial septal defect Ventricular septal defect Baffle leak Air or device embolization Blood loss Interference with atrioventricular value function Arrhythmias; ventricular arrhythmias, complete heart block Balloon and stent dilations Pulmonary artery stenosis Pulmonary artery tear and hemorrhage Pulmonary edema: high flow False aneurysm Right ventricle ischemia Pulmonary valve stenosis As above Pulmonary valve regurgitation Mitral valve stenosis Mitral insufficiency Pulmonary hypertension Coarctation of the aorta Aortic dissection Hypertension Right ventricular conduit/percutaneous pulmonary valve Conduit disruption False aneurysms Stent embolization Pulmonary hemorrhage from distal wire injury Atrial septostomy Transposition of the great arteries, mitral stenosis (atresia) with restrictive atrial septum, hybrid procedure Perforation of the heart and tamponade Atrial arrhythmia Mitral valve injury Transcatheter pulmonary valve replacement Tetralogy of Fallot status post–surgical repair Pulmonary conduit tear or rupture Coronary artery compression The use of percutaneously inserted mechanical circulatory support is a rapidly expanding field in adult cardiology,65 and some of these technologies are applicable to pediatric patients.66 An awareness of newer percutaneous means for providing short-term hemodynamic support is important for critical care physicians and is an area that is rapidly evolving Conclusion In conclusion, cardiac catheterization can provide invaluable diagnostic information in select patients and is increasingly used for therapeutic purposes From the intensive care perspective, it is helpful to understand the risks, benefits, and limitations of cardiac catheterization and to recognize the importance of team communication to facilitate safe and effective procedural planning and conduct Key References Abman SH, Hansmann G, Archer SL, et al Pediatric pulmonary hypertension: Guidelines from the American Heart Association and American Thoracic Society Circulation 2015;132(21):2037-2099 Bergersen L, Gauvreau K, Foerster SR, et al Catheterization for Congenital Heart Disease Adjustment for Risk Method (CHARM) JACC Cardiovasc Interv 2011;4(9):1037-1046 Feltes TF, Bacha E, Beekman RH III, et al Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association Circulation 2011; 123(22):2607-2652 Hill KD, Du W, Fleming GA, et al Validation and refinement of the catheterization RISk score for pediatrics (CRISP score): An analysis from the congenital cardiac interventional study consortium Catheter Cardiovasc Interv 2019;93(1):97-104 Nykanen DG, Forbes TJ, Du W, et al CRISP: Catheterization RISk score for pediatrics: a report from the Congenital Cardiac Interventional Study Consortium (CCISC) Catheter Cardiovasc Interv 2016;87(2):302-309 Odegard KC, Vincent R, Baijal R, et al SCAI/CCAS/SPA expert consensus statement for anesthesia and sedation practice: recommendations for patients undergoing diagnostic and therapeutic procedures in the pediatric and congenital cardiac catheterization laboratory Catheter Cardiovasc Interv 2016;88(6):912-922 Wilkinson JL Haemodynamic calculations in the catheter laboratory Heart 2001;85(1):113-120 The full reference list for this chapter is available at ExpertConsult.com e1 References Freedom RM, Lock J, Bricker JT Pediatric cardiology and cardiovascular surgery: 1950-2000 Circulation 2000;102(20 suppl 4):IV58IV68 Wilkinson JL Haemodynamic calculations in the catheter laboratory Heart 2001;85(1):113-120 Nishimura RA, Carabello BA Hemodynamics in the cardiac catheterization laboratory of the 21st century Circulation 2012;125(17): 2138-2150 LaFarge CG, Miettinen OS The estimation of oxygen consumption Cardiovasc Res 1970;4(1):23-30 Mullins CE Cardiac Catheterization in Congenital Heart Disease: Pediatric and Adult Malden, Mass.: Blackwell Futura; 2006 van der Stelt F, Siegerink SN, Krings GJ, Molenschot MMC, Breur J Three-dimensional rotational angiography in pediatric patients with congenital heart disease: a literature review Pediatr Cardiol 2019;40(2):257-264 Feltes TF, Bacha E, Beekman RH III, et al Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association Circulation 2011;123(22):2607-2652 McLaughlin VV, Archer SL, Badesch DB, et al ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association Circulation 2009;119(16):22502294 Abman SH, Hansmann G, Archer SL, et al Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society Circulation 2015;132(21):2037-2099 10 Davies RR, Russo MJ, Mital S, et al Predicting survival among high-risk pediatric cardiac transplant recipients: an analysis of the United Network for Organ Sharing database J Thorac Cardiovasc Surg 2008;135(1):147-155, 155.e141-142 11 Little WC, Freeman GL Pericardial disease Circulation 2006; 113(12):1622-1632 12 Adler Y, Charron P, Imazio M, et al 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC) Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS) Eur Heart J 2015;36(42):2921-2964 13 Tsang TS, El-Najdawi EK, Seward JB, Hagler DJ, Freeman WK, O’Leary PW Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy J Am Soc Echocardiogr 1998;11(11):1072-1077 14 Rashkind WJ, Miller WW Creation of an atrial septal defect without thoracotomy A palliative approach to complete transposition of the great arteries JAMA 1966;196(11):991-992 15 Steeg CN, Bierman FZ, Hordof AJ, Hayes CJ, Krongrad E, Barst RJ “Bedside” balloon septostomy in infants with transposition of the great arteries: new concepts using two-dimensional echocardiographic techniques J Pediatr 1985;107(6):944-946 16 McQuillen PS, Hamrick SE, Perez MJ, et al Balloon atrial septostomy is associated with preoperative stroke in neonates with transposition of the great arteries Circulation 2006;113(2):280-285 17 Petit CJ, Rome JJ, Wernovsky G, et al Preoperative brain injury in transposition of the great arteries is associated with oxygenation and time to surgery, not balloon atrial septostomy Circulation 2009; 119(5):709-716 18 Beca J, Gunn J, Coleman L, et al Pre-operative brain injury in newborn infants with transposition of the great arteries occurs at rates similar to other complex congenital heart disease and is not related to balloon atrial septostomy J Am Coll Cardiol 2009;53(19):1807-1811 19 Barker GM, Forbess JM, Guleserian KJ, Nugent AW Optimization of preoperative status in hypoplastic left heart syndrome with intact atrial septum by left atrial decompression and bilateral pulmonary artery bands Pediatr Cardiol 2014;35(3):479-484 20 Kan JS, White Jr RI, Mitchell SE, Gardner TJ Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary-valve stenosis N Engl J Med 1982;307(9):540-542 21 Colli AM, Perry SB, Lock JE, Keane JF Balloon dilation of critical valvar pulmonary stenosis in the first month of life Cathet Cardiovasc Diagn 1995;34(1):23-28 22 McElhinney DB, Lock JE, Keane JF, Moran AM, Colan SD Left heart growth, function, and reintervention after balloon aortic valvuloplasty for neonatal aortic stenosis Circulation 2005;111(4):451458 23 Siddiqui J, Brizard CP, Galati JC, et al Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization J Am Coll Cardiol 2013; 62(22):2134-2140 24 Reich O, Tax P, Marek J, et al Long term results of percutaneous balloon valvoplasty of congenital aortic stenosis: independent predictors of outcome Heart 2004;90(1):70-76 25 Torres A, Vincent JA, Everett A, et al Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment Catheter Cardiovasc Interv 2015;86(5):808-820 26 Brown DW, Dipilato AE, Chong EC, Lock JE, McElhinney DB Aortic valve reinterventions after balloon aortic valvuloplasty for congenital aortic stenosis intermediate and late follow-up J Am Coll Cardiol 2010;56(21):1740-1749 27 Balmer C, Beghetti M, Fasnacht M, Friedli B, Arbenz U Balloon aortic valvoplasty in paediatric patients: progressive aortic regurgitation is common Heart 2004;90(1):77-81 28 Sholler GF, Keane JF, Perry SB, Sanders SP, Lock JE Balloon dilation of congenital aortic valve stenosis Results and influence of technical and morphological features on outcome Circulation 1988;78(2):351-360 29 O’Laughlin MP Catheterization treatment of stenosis and hypoplasia of pulmonary arteries Pediatr Cardiol 1998;19(1):48-56; discussion 57-48 30 Baker CM, McGowan FX, Jr., Keane JF, Lock JE Pulmonary artery trauma due to balloon dilation: recognition, avoidance and management J Am Coll Cardiol 2000;36(5):1684-1690 31 Wood AM, Holzer RJ, Texter KM, et al Transcatheter elimination of left-to-right shunts in infants with bronchopulmonary dysplasia is feasible and safe Congenit Heart Dis 2011;6(4):330-337 32 Thomas VC, Vincent R, Raviele A, Diehl H, Qian H, Kim D Transcatheter closure of secundum atrial septal defect in infants less than 12 months of age improves symptoms of chronic lung disease Congenit Heart Dis 2012;7(3):204-211 33 FDA Approves World’s First Device for Treatment of Premature Babies and Newborns with an Opening in Their Hearts (a Common Congenital Defect) 2019 Available at: https://abbott.mediaroom.com/201901-14-FDA-Approves-Worlds-First-Device-for-Treatment-ofPremature-Babies-and-Newborns-with-an-Opening-in-TheirHearts-a-Common-Congenital-Defect Accessed May 13, 2019 34 Sathanandam S, Balduf K, Chilakala S, et al Role of transcatheter patent ductus arteriosus closure in extremely low birth weight infants Catheter Cardiovasc Interv 2019;93(1):89-96 35 Haponiuk I, Chojnicki M, Jaworski R, et al Hybrid approach for closure of muscular ventricular septal defects Med Sci Monit 2013;19:618-624 36 Gibbs JL Treatment options for coarctation of the aorta Heart 2000;84(1):11-13 37 Qureshi SA, Rosenthal E, Tynan M Should balloon angioplasty be used instead of surgery for native aortic coarctation? Heart 1997; 77(1):86-87 38 Rao PS Should balloon angioplasty be used instead of surgery for native aortic coarctation? Br Heart J 1995;74(6):578-579 e2 39 Torok RD, Campbell MJ, Fleming GA, Hill KD Coarctation of the aorta: management from infancy to adulthood World J Cardiol 2015;7(11):765-775 40 Fletcher SE, Nihill MR, Grifka RG, O’Laughlin MP, Mullins CE Balloon angioplasty of native coarctation of the aorta: midterm follow-up and prognostic factors J Am Coll Cardiol 1995;25(3):730734 41 Ovaert C, McCrindle BW, Nykanen D, MacDonald C, Freedom RM, Benson LN Balloon angioplasty of native coarctation: clinical outcomes and predictors of success J Am Coll Cardiol 2000; 35(4):988-996 42 Meadows J, Minahan M, McElhinney DB, McEnaney K, Ringel R, COAST Investigators Intermediate outcomes in the prospective, multicenter Coarctation of the Aorta Stent Trial (COAST) Circulation 2015;131(19):1656-1664 43 Ringel RE, Vincent J, Jenkins KJ, et al Acute outcome of stent therapy for coarctation of the aorta: results of the coarctation of the aorta stent trial Catheter Cardiovasc Interv 2013;82(4):503-510 44 Hill KD, Rhodes JF, Aiyagari R, et al Intervention for recoarctation in the single ventricle reconstruction trial: incidence, risk, and outcomes Circulation 2013;128(9):954-961 45 Akinturk H, Michel-Behnke I, Valeske K, et al Hybrid transcatheter-surgical palliation: basis for univentricular or biventricular repair: the Giessen experience Pediatr Cardiol 2007;28(2):79-87 46 Glatz AC, Petit CJ, Goldstein BH, et al Comparison between patent ductus arteriosus stent and modified Blalock-Taussig shunt as palliation for infants with ductal-dependent pulmonary blood flow: insights from the congenital catheterization research collaborative Circulation 2018;137(6):589-601 47 Bentham JR, Zava NK, Harrison WJ, et al Duct stenting versus modified Blalock-Taussig shunt in neonates with duct-dependent pulmonary blood flow: associations with clinical outcomes in a multicenter national study Circulation 2018;137(6):581-588 48 Gibbs JL, Wren C, Watterson KG, Hunter S, Hamilton JR Stenting of the arterial duct combined with banding of the pulmonary arteries and atrial septectomy or septostomy: a new approach to palliation for the hypoplastic left heart syndrome Br Heart J 1993;69(6):551555 49 Galantowicz M, Cheatham JP Lessons learned from the development of a new hybrid strategy for the management of hypoplastic left heart syndrome Pediatr Cardiol 2005;26(3):190-199 50 Schranz D, Bauer A, Reich B, et al Fifteen-year single center experience with the “Giessen Hybrid” approach for hypoplastic left heart and variants: current strategies and outcomes Pediatr Cardiol 2015;36(2):365-373 51 Davies RR, Carver SW, Schmidt R, Keskeny H, Hoch J, Pizarro C Gastrointestinal complications after stage I Norwood versus hybrid procedures Ann Thorac Surg 2013;95(1):189-195; discussion 195186 52 Bonhoeffer P, Boudjemline Y, Saliba Z, et al Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction Lancet 2000;356(9239): 1403-1405 53 Morray BH, McElhinney DB, Cheatham JP, et al Risk of coronary artery compression among patients referred for transcatheter pulmonary valve implantation: a multicenter experience Circ Cardiovasc Interv 2013;6(5):535-542 54 McElhinney DB, Benson LN, Eicken A, Kreutzer J, Padera RF, Zahn EM Infective endocarditis after transcatheter pulmonary valve replacement using the Melody valve: combined results of prospective North American and European studies Circ Cardiovasc Interv 2013;6(3):292-300 55 Vollroth M, Daehnert I, Kostelka M, Wagner R First case of bloodculture proven Staphylococcus aureus endocarditis of a Sapien(R) XT valve after percutaneous pulmonary valve implantation Eur J Cardiothorac Surg 2015;48(6):e124-e125 56 Nykanen DG, Forbes TJ, Du W, et al CRISP: Catheterization RISk score for Pediatrics: a report from the Congenital Cardiac Interventional Study Consortium (CCISC) Catheter Cardiovasc Interv 2016;87(2):302-309 57 Hill KD, Du W, Fleming GA, et al Validation and refinement of the catheterization RISk score for pediatrics (CRISP score): an analysis from the congenital cardiac interventional study consortium Catheter Cardiovasc Interv 2019;93(1):97-104 58 Bergersen L, Gauvreau K, Foerster SR, et al Catheterization for Congenital Heart Disease Adjustment for Risk Method (CHARM) JACC Cardiovasc Interv 2011;4(9):1037-1046 59 Bergersen L, Gauvreau K, Marshall A, et al Procedure-type risk categories for pediatric and congenital cardiac catheterization Circ Cardiovasc Interv 2011;4(2):188-194 60 Booth KL, Roth SJ, Perry SB, del Nido PJ, Wessel DL, Laussen PC Cardiac catheterization of patients supported by extracorporeal membrane oxygenation J Am Coll Cardiol 2002;40(9):1681-1686 61 desJardins SE, Crowley DC, Beekman RH, Lloyd TR Utility of cardiac catheterization in pediatric cardiac patients on ECMO Catheter Cardiovasc Interv 1999;46(1):62-67 62 Haines NM, Rycus PT, Zwischenberger JB, Bartlett RH, Undar A Extracorporeal Life Support Registry Report 2008: neonatal and pediatric cardiac cases ASAIO J 2009;55(1):111-116 63 Duncan BW, Hraska V, Jonas RA, et al Mechanical circulatory support in children with cardiac disease J Thorac Cardiovasc Surg 1999;117(3):529-542 64 Carmichael TB, Walsh EP, Roth SJ Anticipatory use of venoarterial extracorporeal membrane oxygenation for a high-risk interventional cardiac procedure Respir Care 2002;47(9):1002-1006 65 Rihal CS, Naidu SS, Givertz MM, et al 2015 SCAI/ACC/HFSA/ STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d’intervention) J Card Fail 2015;21(6):499-518 66 Dimas VV, Murthy R, Guleserian KJ Utilization of the Impella 2.5 micro-axial pump in children for acute circulatory support Catheter Cardiovasc Interv 2014;83(2):261-262 e3 Abstract: Cardiac catheterization provides an important diagnostic and therapeutic option to enhance the management of children in the critical care environment Since its inception, the role of cardiac catheterization continues to evolve, now with an increasing repertoire of interventional procedures This chapter aims to improve understanding of the risks, benefits and limitations of cardiac catheterization for the intensive care provider and to recognize the importance of team communication to facilitate safe and effective procedural planning and conduct Key words: cardiac catheterization, congenital heart disease, hemodynamics, septostomy, valvuloplasty, stent angioplasty, transcatheter pulmonary valve ... Haemodynamic calculations in the catheter laboratory Heart 2001;85(1):113-120 The full reference list for this chapter is available at ExpertConsult.com e1 References Freedom RM, Lock J, Bricker JT Pediatric... catheterization continues to evolve, now with an increasing repertoire of interventional procedures This chapter aims to improve understanding of the risks, benefits and limitations of cardiac catheterization