Management of a Patient with Left-to-Right Shunt

  • Christian Bauerfeld
  • Ashok P. Sarnaik
  • Kathleen Meert


We describe the basic pathophysiology of common congenital heart defects with left-to-right shunt. These defects include ostium primum atrial septal defect (ASD), ostium secundum ASD, sinus venosus ASD, coronary sinus ASD, ventricular septal defects, atrioventricular septal defects, patent ductus arteriosus, and aortopulmonary window. The underlying pathophysiology of these defects is a communication between the systemic and pulmonary circulations. This communication allows return of oxygenated blood back to the lungs (left-to-right shunt) leading to volume overload of the right heart and lungs. The amount of shunting determines the degree of symptoms and depends on the size of the defect and the resistance and pressure properties of the pulmonary and systemic circulations. Unrecognized large left-to-right shunts can lead to irreversible pulmonary vascular disease and Eisenmenger syndrome. Medical management includes careful attention to fluid balance, avoidance of indiscriminate oxygen therapy, and appropriate use of inotropic agents, systemic afterload reduction, and positive pressure ventilation.


Left-to-right shunt Atrial septal defect Ventricular septal defect Qp/Qs ratio Eisenmenger syndrome 


  1. 1.
    Bernstein D. Acyanotic congenital heart disease: left-to-right shunt. In: Nelson textbook of pediatrics. 20th ed. Philadelphia: Elsevier; 2016, p. 2189–99.Google Scholar
  2. 2.
    Bernstein D. Heart failure. In: Nelson textbook of pediatrics. 20th ed. Philadelphia: Elsevier; 2016, p. 2282–7.Google Scholar
  3. 3.
    Rossano JW, Price JF, Nelson DP. Treatment of heart failure: medical management. In: Roger’s textbook of pediatric critical care. 5th ed. Philadelphia: Wolters Kluwer; 2016, p. 1170–87.Google Scholar
  4. 4.
    Silberbach M, Hannon D. Presentation of congenital heart disease in the neonate and young infant. Pediatr Rev. 2007;28(4):123–31.CrossRefGoogle Scholar
  5. 5.
    van der Linde D, Yap SC, van Dijk AP, Budts W, Pieper PG, van der Burgh PH, Mulder BJ, Witsenburg M, Cuypers JA, Lindemans J, Takkenberg JJ, Roos-Hesselink JW. Birth prevalence of congenital heart disease worldwide. Am J Cardiol. 2011;108(2):265–71.CrossRefGoogle Scholar
  6. 6.
    Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002;39(12):1890–900.CrossRefGoogle Scholar
  7. 7.
    Schweigmann U, Meierhofer C. Strategies for the treatment of acute heart failure in children. Minerva Cardioangiol. 2008;56(3):321–33.PubMedGoogle Scholar
  8. 8.
    Tume SC, Goldberg J, Molossi S, Bronicki RA. Pharmacologic approach to heart failure in children. Curr Cardiol Rev. 2016;12(2):117–20.CrossRefGoogle Scholar
  9. 9.
    Emmanouilides GC, Moss AJ, Duffie ER Jr, Adams FH. Pulmonary arterial pressure changes in human newborn infants from birth to 3 days of age. J Pediatr. 1964;65:327–33.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Christian Bauerfeld
    • 1
  • Ashok P. Sarnaik
    • 1
  • Kathleen Meert
    • 1
  1. 1.Division of Pediatric Critical Care Medicine, Department of PediatricsChildren’s Hospital of Michigan, Wayne State UniversityDetroitUSA

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