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Transthoracic Echocardiography Using Second Harmonic Imaging with Valsalva Manoeuvre for the Detection of Right to Left Shunts Eur J Echocardiogr 5:176-181, Clarke,N.R.,et al, 2004 See this aricle in Pubmed Article Abstract TTE with Valsalva manoeuvre is as good as TEE in diagnosing shunts. Valsalva manoeuvre increases the size of shunt. Both techniques produce false negative results.

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