Controversies in the definition and management of insignificant left-to-right shunts

Abstract

Haemodynamically insignificant left-to-right shunts are frequently discovered when screening for congenital heart disease, resulting in significant economic and psychosocial impact. A literature search was performed within the National Library of Medicine using the keywords small/insignificant/silent atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA) and patent foramen ovale (PFO). The search was refined by adding the keywords definition, classification and follow-up. Our analysis revealed significant heterogeneity in the evaluation and management of innocent left-to-right shunts. The definitions for small defects vary greatly, making it difficult to distinguish between physiologic and pathologic lesions (eg, a PFO vs a true ASD). Most small defects will partially or completely resolve spontaneously early in life. If spontaneous resolution does not occur, the risk for long-term complications (such as embolic events and endocarditis) is low but poses several practical and ethical issues: immediate discharge versus long-term follow-up, duration and frequency of follow-up, and content and method of discussions with the parents. Additionally, there is controversy pertaining to treatment for PDAs and VSDs, particularly among interventional cardiologists, even though risk/benefit analyses are lacking. Standards and guidelines using consensus opinion for the management of insignificant left-to-right shunts are needed to address the heterogeneity in diagnosis and management as well as use of resources, ethical and psychosocial issues.

Almanac 2014: congenital heart disease

“…26 Recently, mid-term follow-up at a mean duration of 10±7 years after primary aortic stenosis treatment during the 1st year of life showed increased rate of reintervention in patients with balloon valvuloplasty (HR 4.0, p=0.001). 27 In a prospective randomised controlled trial, 229 children with perimembranous ventricular septal defect were assigned to surgical or interventional defect closure.…”

Almanac 2014: Congenital Heart Disease.

“…26 Nedavno rezultati srednjeročnog praćenja od 10 ± 7 godina nakon primarnog liječenja aortne stenoze tijekom prve godine života pokazali povećanu stopu ponovne intervencije u pacijenata liječenih balonskom valvuloplastikom (HR 4,0; p = 0,001).…”

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“…[2][3][4][5][6][7] Foramen ovale is easily evaluated by echocardiography. [1][2][3][4][5][6][7] Echocardiography is also commonly employed to guide the Rashkind procedure as well as to evaluate its result. 8 9 Despite this no clear echocardiographic criteria exist at present to define a foramen ovale 7 neither to judge if it is restrictive or less.…”

“…On the other hand, defects >4 mm are generally considered no more as PFO but as true atrial septal defects 1 Many controversies however remain in the differentiation between a PFO and an atrial septal defect 1 with most cardiologists using the size or flap presence while the volume and/or echocardiographic visibility of blood traversing the septal opening and the visibility of the opening during part or all of the cardiac cycle or location of the opening within the atrial septum are other findings commonly employed. 1 There is no further consensus regarding the echocardiographic projections to be employed for measurement (ie, subcostal view, four-chamber view, etc) 1-7 and the use of 3D echocardiography has been poorly evaluated so far.…”

“…1 There is no further consensus regarding the echocardiographic projections to be employed for measurement (ie, subcostal view, four-chamber view, etc) 1-7 and the use of 3D echocardiography has been poorly evaluated so far.…”