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© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION The importance of a wellperformed cardiac catheterisation in adults with congenital heart disease (CHD) cannot be overstated. Despite the modernday diagnostic benefits of echocardiography and crosssectional imaging, diagnostic cardiac catheterisation remains the most accurate method of assessing intracardiac filling pressures, valve gradients, shunt lesions and, in many cases, anatomy. When properly performed, cardiac catheterisation serves as a tool to guide decisions for medical and invasive intervention, identify causes of occult symptoms when noninvasive image has failed to do so and aid in prognostication. Given the anatomic variability and haemodynamic complexities of patients with CHD, cardiac catheterisation is often performed at CHD specialty centres by cardiologists with expertise in CHD, per the 2018 American Heart Association/American College of Cardiology (AHA/ ACC) Guidelines for the Management of Adults with Congenital Heart Disease (Class I, Level C). However, as the population of adults with CHD continues to increase, many of these patients are being seen and cared for in the community. 3 The purpose of this manuscript is to review some of the common tools and techniques employed by interventionalists who specialise in CHD to serve as a guide for any who may be called on to perform diagnostic cardiac catheterisations in the service of their patients. The approach to catheterisation in patients with CHD differs from those with anatomically normal cardiovascular systems in a few key ways. Often, patients with CHD have undergone one or more surgical or transcatheter interventions altering their original anatomy and physiology. Vascular abnormalities may exist either in concert with the cardiac defect (ie, interrupted inferior vena cava) or as a result of multiple prior transcatheter interventions. A complete diagnostic cardiac catheterisation in patients with more complex disease often involves angiography of vascular and intracardiac structures and may benefit from the use of biplane imaging. Of additional importance, many patients with complex CHD have undergone cardiac catheterisation procedures throughout childhood resulting in posttraumatic stress disorder, exacerbated during subsequent procedures no matter how routine. Given these challenges, an indepth understanding of a patient’s medical and social history is of paramount importance to a successful procedure. The following review focuses on key elements of the precatheterisation work up of CHD patients, tools and techniques for obtaining accurate haemodynamics and angiograms and technical approaches to patients with particularly complex native or postsurgical anatomy and physiology.