Outpatient management of isolated left-to-right shunt lesions in pediatric patients with congenital heart disease is the focus of a new 2026 ACC Concise Clinical Guidance report. Published in JACC, the report aims to provide clinicians with a decision support framework for managing common left-to-right shunt lesions, including atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA) and atrioventricular septal defect (AVSD), in the current absence of evidence-based clinical practice guidelines.

Led by Writing Committee Chair Ritu Sachdeva, MBBS, FACC; and Vice Chair Anitha Parthiban, MBBS, FACC, the document provides a general decision support tool for the outpatient management of left-to-right shunt lesions that starts with initial evaluation, including electrocardiogram and transthoracic echocardiography, followed by management recommendations guided by symptoms; chamber enlargement; associated complications, such as valvular regurgitation; and concern for pulmonary vascular disease. Patients with hemodynamically significant lesions and/or complications should be considered for intervention, according to the authors.

Additionally, the document offers specific algorithms for ASD, VSD, PDA and AVSD, with each addressing anatomic and physiologic considerations, as well as offering comprehensive guidance for outpatient management of more frequently encountered clinical scenarios. For example, the VSD algorithm includes management recommendations for isolated muscular VSD, isolated nonmuscular VSD, and repaired VSD, while the PDA algorithm addresses management of both isolated PDA and post-intervention. Similarly, the AVSD algorithm includes guidance on management of unrepaired isolated AVSD, as well as repaired AVSD.

The authors stress that the recommendations, while comprehensive, are not all-encompassing. "The overarching goal is to provide broad guidance for frequently encountered clinical scenarios, while allowing flexibility for clinicians to tailor care to individual patients," they write. "Although simplified for practicality and ease of use, the algorithms may not apply to every patient or encompass all possible clinical presentations."

Going forward, they suggest that implementation of the ACC Concise Clinical Guidance report may help reduce practice variation and appropriate use of therapies and treatment. They add that clinician groups may also use the algorithms for practice-based learning that supports maintenance of certification and continuing competency. Ultimately, use of the document may result in studies that can build a foundation for future clinical practice guidelines, they write.