A right-to-left shunt occurs because the RV fills more easily than does the LV and the pulmonary vascular resistance is lower than the systemic. Therefore, pulmonary blood flow may be two to four times greater than the systemic blood flow, resulting in a dilated RA, RV, and PA. Since normal atrial pressures are low, there is no transmission of pressure to the pulmonary arteries. A contrast study is routine in patients with a dilated right side since color flow Doppler is not very sensitive at detecting ASDs. Many times, the dilated RA and RV are the first echocar- diographic sign of an ASD. If an ASD cannot be confirmed on TTE, and other causes of right heart dilation are not seen (such as TR), then a TEE (or cardiac MRI) is indicated to exclude a sinus venosus–type ASD or partial anomalous pulmonary venous return (or both).