title: Subspecialty surveillance of long-term course of small and moderate muscular ventricular septal defect: heterogenous practices, low yield.
abstract: BACKGROUND
  No expert consensus guides practice for intensity of ongoing pediatric cardiology surveillance of hemodynamically insignificant small and moderate muscular ventricular septal defect (mVSD). Therefore, despite the well-established benign natural history of mVSD, there is potential for widely divergent follow up practices. The purpose of this investigation was to evaluate (1) variations in follow up of mVSD within an academic children's hospital based pediatric cardiology practice, and (2) the frequency of active medical or surgical management resulting from follow up of mVSD.
  
  
  METHODS
  We retrospectively reviewed records of 600 patients with isolated mVSD echocardiographically diagnosed between 2006 and 2012. Large mVSD were excluded (n = 4). Patient age, gender, echocardiographic findings, provider, recommendations for follow up, and medical and surgical management were tabulated at initial and follow up visits. Independent associations with follow up recommendations were sought using multivariate analysis.
  
  
  RESULTS
  Initial echocardiography showed small single mVSD in 509 (85%), multiple small mVSD in 60 (10%), and small-to-moderate or moderate single mVSD in 31 (5%). The mean age at diagnosis was 15.9 months (0-18.5 years) and 25.7 months (0-18.5 years) at last follow up. There was slight female predominance (56.3%). Fourteen pediatric cardiology providers recommended 316 follow up visits, 259 of which were actually accomplished. There were 37 other unplanned follow up visits. No medical or surgical management changes were associated with any of the follow up visits. The proportion of patients for whom follow up was advised varied among providers from 11 to 100%. Independent associations with recommendation for follow up were limited to the identity and clinical volume of the provider, age of the patient, and the presence of multiple, small-to-moderate, or moderate mVSD.
  
  
  CONCLUSIONS
  In this large series of moderate or smaller mVSD, pediatric cardiology follow up was commonly recommended but resulted in no active medical or surgical management. Major provider based inconsistency in intensity of follow up of mVSD was identified, but is difficult to justify.
authors.forename: Erik L
authors.initials: EL
authors.lastname: Frandsen
authors.forename: Aswathy V
authors.initials: AV
authors.lastname: House
authors.forename: Yunbin
authors.initials: Y
authors.lastname: Xiao
authors.forename: David A
authors.initials: DA
authors.lastname: Danford
authors.affiliation: Division of Pediatric Cardiology, University of Nebraska College of Medicine and Children's Hospital and Medical Center, 8200 Dodge St, Omaha, NE 68114, USA. skutty@unmc.edu.
authors.forename: Shelby
authors.initials: S
authors.lastname: Kutty
mesh_terms: D000293:Adolescent; D016507:Cardiology Service, Hospital; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D005260:Female; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging / Q000628:therapy*; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies