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  1. Massimiliano Cantinotti1,
  2. Nadia Assanta1,
  3. Bruno Murzi1,
  4. Giorgio Iervasi1,2,
  5. Isabella Spadoni1
  1. 1 Fondazione G. Monasterio CNR-Regione Toscana, Massa and Pisa, Italy
  2. 2 Institute of Clinical Physiology, Pisa, Italy
  1. Correspondence to Dr Massimiliano Cantinotti, Fondazione G. Monasterio CNR-Regione Toscana, Ospedale del Cuore, via Aurelia Sud, Massa 54100, Italy; cantinotti{at}

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To the Editor: We recently published a review (which now features in this issue)1 on the controversies in the definition and management of insignificant left-to-right shunt commonly observed during a routine echocardiographic screening.

As an additional remark, however, we would like to point out an important aspect regarding the echocardiographic definition of restrictive patent foramen ovale (PFO).

Adequate blood flow mixing trough a PFO is essential for survival in neonates and infants with various congenital heart diseases including transposition of the great arteries, hypoplastic left heart syndrome, tricuspid atresia, various forms of univentricular heart, total anomalous pulmonary venous return, etc.2–7

In these diseases signs of PFO restriction should alert the clinician and require urgent Rashkind procedure or anticipation of surgical correction/palliation.2–7

Foramen ovale is easily evaluated by echocardiography.1–7

Echocardiography is also commonly employed to …

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  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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