Congenital Heart Disease and Litigation: What Attorneys Should Know

A two-day-old infant is noted to appear dusky during feeding. The observation is not escalated. Pulse oximetry screening, which is required by state law, is not performed before discharge. The baby goes home. Within hours, the infant becomes deeply cyanotic and unresponsive. In the emergency department, oxygen saturations are critically low. An echocardiogram reveals d-transposition of the great arteries — a critical congenital heart defect in which the two main arteries leaving the heart are reversed. This defect reliably causes low oxygen levels and is one of the conditions that newborn pulse oximetry screening is specifically designed to detect. Had screening been performed — or had the observation of duskiness prompted further evaluation — the diagnosis would likely have been made before discharge, allowing for a planned, controlled intervention rather than an emergent resuscitation.

This scenario — a missed critical congenital heart defect that should have been caught by standard screening — is one of the most common patterns seen in congenital heart disease litigation. Understanding why these cases arise, and what distinguishes an unavoidable outcome from a potentially preventable injury, is essential for any attorney evaluating a case involving congenital heart disease.

What Is Congenital Heart Disease?

Congenital heart disease (CHD) refers to structural abnormalities of the heart or great vessels that develop before birth. It is the most common type of birth defect, affecting approximately 1 in 100 live births. Severity ranges widely:

• Mild defects (e.g., small ventricular septal defect) — may close on their own and never require treatment.
• Moderate defects (e.g., tetralogy of Fallot, coarctation of the aorta) — typically require surgical repair, often in infancy.
• Severe or complex defects (e.g., hypoplastic left heart syndrome, single ventricle physiology) — require multiple staged surgeries beginning in the newborn period, with lifelong specialty care.

Each diagnosis carries its own management pathway, expected complications, and long-term prognosis. This variability is precisely what makes expert review essential in litigation.

Why Congenital Heart Disease Appears in Litigation

CHD cases arise in litigation for several recurring reasons. Understanding these patterns helps attorneys identify viable claims early.

Delayed or Missed Diagnosis

This is the most frequent allegation. Examples include:

• Failure to recognize signs of cyanosis (blue discoloration) or poor perfusion in a newborn.
• Missed critical congenital heart disease despite abnormal findings on examination.
• Delayed referral to a pediatric cardiologist when clinical findings warranted further evaluation.
• Failure to obtain an echocardiogram when indicated.

The legal question is rarely whether the diagnosis was difficult. The focus is whether the clinical presentation required additional evaluation under the applicable standard of care — and whether that evaluation was performed.

Newborn Pulse Oximetry Screening

Pulse oximetry screening — a simple, noninvasive test that measures oxygen levels — is now mandated for all newborns in every U.S. state and territory. It was added to the U.S. Recommended Uniform Screening Panel in 2011 and has been shown to reduce infant cardiac deaths.

However, attorneys should understand two critical points:

1. Pulse oximetry does not detect every congenital heart defect. Its overall sensitivity is approximately 76%, meaning roughly one in four critical defects may be missed by screening alone. Certain defects — particularly left-sided obstructive lesions like coarctation of the aorta — are especially prone to false-negative results because they may not cause low oxygen levels in the first days of life. The sensitivity of pulse oximetry for coarctation may be as low as 21%.
2. A "passing" pulse oximetry screen does not rule out congenital heart disease. The American Academy of Pediatrics emphasizes that screening is only one tool and should not be relied upon in isolation. Clinical examination, prenatal imaging, and a high index of suspicion remain essential.

When pulse oximetry screening is not performed, performed incorrectly, or its results are misinterpreted, it may form the basis of a malpractice claim — particularly when the missed defect is one that reliably causes low oxygen levels and would have been detected by proper screening.

Prenatal Diagnosis

Modern fetal echocardiography can detect many major congenital heart defects before birth. Prenatal diagnosis allows families and medical teams to plan delivery at a center equipped for immediate neonatal cardiac care. Potential issues in litigation include:

• Failure to recognize abnormal findings on routine prenatal ultrasound.
• Inadequate referral for fetal echocardiography when risk factors or abnormal screening results are present.
• Delayed counseling regarding delivery planning.

Not every congenital defect is detectable prenatally. Prenatal detection rates remain under 60% in many areas of the United States, and certain defects — such as coarctation of the aorta — are particularly difficult to identify on fetal imaging unless there is significant associated anatomy such as a hypoplastic aortic arch or marked right heart enlargement. This makes expert review essential to determine whether a missed prenatal diagnosis fell below the standard of care or reflected a known limitation of current imaging.

Surgical and Interventional Care

Complex CHD often requires open-heart surgery, cardiac catheterization, ECMO (mechanical circulatory support), and multiple staged operations. Litigation in this area may involve:

• Surgical complications or technical errors.
• Delayed recognition of postoperative complications.
• Inadequate ICU monitoring.
• Communication failures between care teams.

A review of 177 congenital cardiac surgery malpractice cases in the United States found that procedural errors were the most common allegation (45% of cases), cardiac arrest was the most frequent clinical event (54%), and the average plaintiff award was approximately $9.4 million.

Emergency Department Presentations

Children with known congenital heart disease frequently present to emergency departments with common pediatric complaints — fever, vomiting, respiratory symptoms, fatigue, or syncope. While many of these illnesses are unrelated to the underlying heart condition, CHD can fundamentally alter risk assessment and management decisions.

For example, a child with single ventricle physiology who presents with fever requires a different evaluation than a healthy child with the same complaint. Understanding the child's baseline anatomy, prior surgeries, and current physiology is critical when determining whether emergency care met the standard of care.

Neurodevelopmental Consequences

Attorneys evaluating damages in CHD cases should be aware that congenital heart disease — particularly complex defects requiring surgery in infancy — carries significant neurodevelopmental risks that extend far beyond the heart.

Children with complex CHD are at increased risk for:

• Delays in motor and language development.
• Deficits in executive function, attention, and working memory.
• Learning disabilities and lower academic achievement — scoring an average of 10% to 13% lower on achievement tests, with nearly half requiring some form of remedial school services.
• Higher rates of attention deficit hyperactivity disorder symptoms.
• Social and behavioral difficulties.
• Anxiety and depression, with a lifetime prevalence estimated at 50% in individuals with CHD.

These neurodevelopmental consequences are recognized as the most prevalent noncardiac comorbidity in CHD. The American Heart Association has published a scientific statement specifically addressing neurodevelopmental evaluation and management in children with congenital heart disease, underscoring the significance of these outcomes.

For litigation purposes, neurodevelopmental injuries are often central to damages calculations, particularly in cases involving delayed diagnosis where earlier intervention might have reduced the severity of neurological injury.

Understanding Causation

One of the most challenging issues in CHD litigation is distinguishing:

• The natural progression of the underlying condition.
• Unavoidable complications inherent to complex cardiac care.
• Injuries resulting from delayed diagnosis or substandard care.

Key questions include:

• Would earlier intervention likely have changed the outcome?
• Did the alleged delay contribute to permanent injury — cardiac, neurological, or developmental?
• Was the complication foreseeable and potentially preventable?
• Was the patient's anatomy unusually complex?
• Were accepted pediatric cardiology guidelines followed?

These questions require careful review of the complete medical record and an understanding of both current evidence and the child's specific cardiac diagnosis.

Life Expectancy and Long-Term Survival

Survival for individuals with CHD has improved dramatically. Approximately 80% to 85% of individuals born with CHD now survive to age 35, and the median age at death for adults with CHD has increased from 37 years in 2002 to 57 years in 2007. For patients with no additional risk factors, survival may approach that of the general population.

However, survival varies significantly by defect severity:

• Mild defects: 25-year cumulative survival approximately 95%.
• Moderate defects: survival close to but below the general population.
• Severe or complex defects: substantially reduced, with 25-year survival as low as 44% for single ventricle physiology.

These figures are directly relevant to damages calculations, particularly in wrongful death cases and cases involving life care planning.

Damages in Congenital Heart Disease Cases

Beyond the immediate medical injury, damages in CHD cases may include:

• Lifelong medical costs — including additional surgeries, cardiac catheterizations, medications, and specialty follow-up.
• Neurodevelopmental services — speech therapy, occupational therapy, physical therapy, special education, and behavioral health services.
• Reduced earning capacity — related to cognitive, developmental, or physical limitations.
• Reduced life expectancy — particularly in complex defects.
• Pain and suffering — including the burden of repeated hospitalizations and procedures.
• Loss of quality of life — exercise limitations, social difficulties, and psychological impact.

In congenital cardiac surgery litigation, defendant verdicts have been associated with cases involving patient mortality — in part because future healthcare expenses are inapplicable when the patient has died, resulting in lower average awards and settlements compared with cases involving surviving patients with permanent injuries.

Common Misconceptions

• "A heart murmur always indicates malpractice." Many innocent murmurs are entirely normal in infants and children, while some serious congenital heart defects produce little or no murmur.
• "Normal pulse oximetry excludes congenital heart disease." Pulse oximetry screening has an overall sensitivity of approximately 76%, and for certain defects like coarctation, sensitivity may be as low as 21%. A normal result significantly reduces — but does not eliminate — the possibility of critical CHD.
• "Congenital heart disease explains every poor outcome." Children with CHD remain entitled to appropriate medical evaluation and timely treatment. The presence of an underlying condition does not eliminate the obligation to meet the applicable standard of care.

Medical Records That Often Matter

Thorough case evaluation depends on reviewing:

• Prenatal imaging reports.
• Pediatric cardiology consultations.
• Echocardiograms and cardiac catheterization reports.
• Operative notes and perfusion records.
• Intensive care documentation.
• Emergency department records.
• Growth, developmental, and neurodevelopmental assessments.
• Longitudinal outpatient follow-up.

Isolated records rarely provide the full clinical picture. The trajectory of care — from prenatal screening through long-term follow-up — is often where the critical questions lie.

The Value of Specialty Expertise

Congenital heart disease encompasses hundreds of distinct anatomical variations and management strategies. Evaluating these cases requires expertise beyond general cardiology or general pediatrics.

An experienced pediatric cardiology expert can assist attorneys by:

• Interpreting complex cardiac anatomy and physiology.
• Reviewing diagnostic studies including echocardiograms, catheterization data, and imaging.
• Assessing adherence to the standard of care based on current evidence and guidelines.
• Evaluating medical causation — distinguishing preventable injury from the natural history of disease.
• Explaining technical concepts in language accessible to judges and juries.
• Providing objective, evidence-based opinions supported by current medical literature.

For attorneys handling cases involving congenital heart disease, early consultation with a board-certified pediatric cardiologist — before depositions are scheduled or expert reports are due — can fundamentally shape case strategy by clarifying the medical issues, identifying strengths and weaknesses, and supporting informed litigation decisions.