We read with great interest the focused update on guidelines for the cardiac sonographer in the performance of contrast echocardiography by Porter et al . recently published in the Journal . In the section on safety in patients with patent foramen ovales and congenital heart diseases, the writing group stated that they do not consider patients with small degrees of right-to-left shunting through patent foramen ovales (transient appearance of saline contrast without opacification of the left atrial or left ventricular cavity) at increased risk for adverse events with the use of ultrasound contrast agents (UCAs). Our recent observational study was the first to systematically assess the use of UCAs in patients with intracardiac shunts ( n = 418). We reported no adverse neurologic or embolic events in patients with intracardiac shunts (excluding patients with cyanotic congenital heart disease) associated with the use of UCAs, and we emphasized that the overall incidence of adverse reactions to UCAs in general is low. Our observational study findings lend support to the stance adopted by Porter et al . We agree that there is no evidence to suggest any adverse safety signal with the use of UCAs in patients with patent foramen ovales, and the benefits of these agents (improved patient care and reduction in unnecessary downstream testing by enhanced echocardiographic accuracy) clearly outweigh the risks.