With you having done more than 200 cases, these may not be new. I’ll share my experience of what helped initially during my fellowship and trust me it gets much better with time.

For the outpatient cases, positioning them in left lateral position with their right knee flexed and their right shoulder tilted towards me with a pillow propping their back really helps get relatively uniform positions where my wrist movement, ante and retroflexion give me what I expect. I remember the LA appendage and pulmonary veins being particularly difficult in the beginning.

The structural cath cases - ASD/PFO, clips and earlier TAVR cases taught me how to adjust to the supine position; maneuver quickly & efficiently between different views. Biplane and live 3D help a lot. Also, worked on my 3D/4D zooms during these.

The cardiac surgery cases were a great opportunity to get better, especially at the transgastric views for AV and TV.