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Background: The mortality of diagnostic catheterization is very low but still exists. Large series have documented left main disease as the most important anatomical risk factor but have not clarified the mechanism., Objectives: To determine the mortality of diagnostic catheterization in a single high volume centre over a 9 year period and assess any change during this period; to compare this experience with that of larger multicentre surveys; to identify the clinical and anatomical risk factors; to investigate the mechanism of the event; to develop guidelines for prevention, Methods: Cardiac catheterization records were reviewed over a 9 year period and patients dying during or within 24 hours were identified. The clinical and anatomical profile of the patients who died were compared with the overall group to search for independent risk factors. The angiograms of the deaths were reviewed for a mechanism., Results: There were 30 deaths in 42,345 procedures (0.071%). There was no change in the incidence over the 9 years. Left main coronary disease was an overwhelming risk factor (incidence 0.7%, p < .002 compared to all other subgroups) and no other anatomical subgroup including triple vessel disease was at greater risk than the overall group. Dissection of the left main coronary artery by the diagnostic catheter was the mechanism of death in 20 cases (67%), Conclusions: Left main disease and catheter induced trauma are the most important risk factor for and mechanism of death during diagnostic catheterization and may account for the unchanging incidence. Technical guidelines are described which may reduce this risk.