Consultation with providers with ACHD expertise may be substituted if the procedure is urgent such that timely transfer is not feasible. An ACHD program has additional resources such as cardiac anesthesia, congenital cardiac surgery, and specialty cardiac imaging, should the need for those services arise during or after the procedure. (Continued) CLINICAL STATEMENTS AND GUIDELINES are also valuable in the evaluation of patients with ACHD. Some tools (eg, echocardiography) are reg- ularly used in the serial evaluation of patients with ACHD, whereas other tools (eg, CMR and CCT) may have more utility in the evaluation and management of patients with ACHD than in patients with acquired cardiovascular disease (Tables 7 and 8). Cost and risk to patients can be minimized by ensuring studies are acquired and interpreted by centers and providers with CHD expertise. Administration of anesthesia for invasive procedures in patients with ACHD AP classification IB-D, IIA-D, and IIIA-D* Performed by, or in collaboration with, an anesthesiologist with expertise in the management of patients with ACHD. ACHD-specific issues need to be addressed when considering anesthesia, including underlying cardiac physiology and hemodynamics, and the effects of anesthetic medications and ventilation strategies. The application of anesthesia for laparoscopic procedures can be especially challenging in Fontan patients. Significant cardiovascular and respiratory alterations may occur as a result of increased intra-abdominal pressure and decreased venous return. Abdominal insufflation may lead to lower preload and hypotension, while at the same time elevating systemic vascular resistance and compromising cardiac output. Elevations in pulmonary vascular resistance attributable to hypercarbia can be caused by either direct carbon dioxide absorption or hypoventilation.S3.3-19 If clinical urgency precludes transfer, consultation with an anesthesiologist with ACHD expertise would be of benefit to on-site providers who do not have ACHD expertise. 