it may indicate a shunt, such as a patent foramen ovale, atrial septal defect, ventricular septal defect or arteriovenous malformations in the lungs. If a doctor deems it necessary, a stress TTE may be performed. It can be accomplished by either exercising on a bike or treadmill, or by medicine given through an IV along with a contrast agent to make the bodily fluids show up brighter. It allows a comparison between the heart at rest and the heart when it is beating at a faster rate. (Transthoracic Echocardiogram, n.d.) There are some risks associated when having an echocardiogram performed. It is possible that the images will not show up clearly enough, which can cause a misdiagnosis. Indications There are numerous indications for a TTE: Non-specific symptoms if cardiac etiology is suspected: Fatigue Dyspnea Heart failure Heart murmur or known valve disease Chemotherapy (cardiotoxic) Chest pain for evaluation of wall motion abnormalities Congenital heart disease Endocarditis Hypoxemia for shunt evaluation Examination A typical TTE examination is done by either a cardiologist or a cardiac sonographer. It is a non-invasive test that can be done in many settings that include clinic exam room, inpatient rooms, and exam rooms dedicated to echo imaging. Examination involves using an echo probe at various positions or windows to obtain views of the heart (thus capturing images/videos for later playback while formally "reading" the study to come up with the findings). Examination is usually done while lying flat and tilted onto the left side to bring the heart into better view. Ultrasound gel is used to improve the acoustic windows and increase quality of the captured images. Overall, an uncomplicated TTE exam takes less than 30 minutes. Limited studies (i.e., looking at only specific structures) can be done as a follow up exam to a full study, or can be done as "point of care" to answer specific questions in the appropriate setting. For example, critically ill patients often have "bedside ultrasounds" performed to assess particular questions the treating team has about their status. This could be looking for cardiac tamponade and acute valve regurgitation. Often, this may include examination of other organ systems such as lungs for effusions or the focused assessment with sonography for trauma. Interpretation of the exam can be done by anyone trained in reading echocardiograms. However, this is often limited to cardiologists for "formal reading" of these studies. Anesthesiologists can perform