Lawrence G Rudski

McGill University, Montréal, Quebec, Canada

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Publications (30)142.68 Total impact

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    ABSTRACT: We evaluate the incidence of complications associated with the use of nitrates in patients presenting with acute pulmonary edema and concomitant moderate or severe aortic stenosis compared with patients without aortic stenosis. Nitrates are contraindicated in severe aortic stenosis because of the theoretical yet unproven risk of precipitating profound hypotension. A cohort design with retrospective chart review study was conducted at two Canadian hospitals. Patients with aortic stenosis (moderate or severe) and without aortic stenosis were included if they presented with acute cardiogenic pulmonary edema, received intravenous or sublingual nitroglycerin, and had an echocardiography report available. The primary outcome was clinically relevant hypotension, defined as hypotension leading to any of the following predefined events: nitroglycerin discontinuation, intravenous fluid bolus, vasopressor use, or cardiac arrest. The secondary outcome was sustained hypotension, defined as a systolic blood pressure less than 90 mm Hg and lasting greater than or equal to 30 minutes. The cohort consisted of 195 episodes of acute pulmonary edema, representing 65 episodes with severe aortic stenosis (N=65) and an equal number of matched episodes with moderate aortic stenosis (N=65) and no aortic stenosis (N=65). Nitroglycerin was administered intravenously only in 70% of cases, intravenously and sublingually in 25%, and sublingually only in the remaining 5%. After adjustment for sex, initial systolic blood pressure, furosemide dose, and use of noninvasive ventilation, moderate and severe aortic stenosis were not associated with clinically relevant hypotension after receipt of nitroglycerin (adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.40 to 2.37 for moderate aortic stenosis; adjusted OR 0.99, 95% CI 0.41 to 2.41 for severe aortic stenosis). The incidence of clinically relevant hypotension was 26.2% for moderate and severe aortic stenosis and 23.1% in the no aortic stenosis reference group. The secondary outcome of sustained hypotension occurred in 29.2% of patients with severe aortic stenosis, 16.9% with moderate aortic stenosis, and 13.8% in the no aortic stenosis group (adjusted OR for severe aortic stenosis 2.34; 95% CI 0.91 to 6.01). In this retrospective study, neither moderate nor severe aortic stenosis was associated with a greater risk of clinically relevant hypotension requiring intervention when nitroglycerin was used for acute pulmonary edema. Future studies should investigate safety and efficacy of nitroglycerin for patients with aortic stenosis because this study was limited by a small sample size and design limitations. Cautious use of nitroglycerin in patients with moderate or severe aortic stenosis and presenting with acute pulmonary edema may be a safer strategy than traditionally thought. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Annals of emergency medicine 05/2015; DOI:10.1016/j.annemergmed.2015.03.027 · 4.33 Impact Factor
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    ABSTRACT: Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity. A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area. TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair. © 2015 American Heart Association, Inc.
    Circulation Cardiovascular Imaging 05/2015; 8(5). DOI:10.1161/CIRCIMAGING.114.002714 · 6.75 Impact Factor
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    ABSTRACT: Several echocardiographic measures have prognostic value in heart failure (HF). However, no definitive data exists on how changes in these parameters with treatment affect survival in this patient population. We hypothesized that early improvement on echocardiography could predict long-term survival. We conducted a retrospective review of 404 patients seen in HF clinic between 2002-2008 (6.5 years). Patients had an echocardiogram ≤1 year prior to and another ≥1 month (10±7 months) after treatment onset. We studied changes in standard echocardiographic parameters, including left (LV) and right (RV) ventricular size and/or function (systolic and/or diastolic), and valvular (mitral and tricuspid) function and pulmonary artery pressure. Survival curves and hazard ratios were generated for patients showing improvement on the second echocardiogram versus those who did not. Multivariable analyses were performed adjusting for age, gender, ischemic etiology and significant baseline echocardiographic parameters. Average follow-up was 2.9±1.5 years. Improvement in LV end-systolic dimension, RV function and mitral regurgitation were independent predictors of 5-year survival (p<0.05) and, importantly, more predictive than baseline values of these parameters alone (higher hazard ratios). Early echocardiographic improvement is strongly associated with 5-year survival in patients with HF. Serial echocardiograms may aid in stratifying patient care. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of cardiac failure 04/2015; 21(6). DOI:10.1016/j.cardfail.2015.04.002 · 3.07 Impact Factor
  • Shoshana Gal Portnoy · Lawrence G Rudski
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    ABSTRACT: The ability to properly evaluate the right ventricular size and function can have important consequences for clinical management and prognosis. Echocardiography is and will remain the leading method of right ventricle (RV) assessment due to its ease of use and wealth of diagnostic information provided. Understanding the various strengths and limitations of the diverse echocardiographic methods of RV assessment can allow a systematic approach to resolve situations where one's quantitative parameters are not necessarily concordant. Quantification of RV volume can be done by two-dimensional (2D) and three-dimensional (3D) echocardiography. Measurements of RV systolic function include fractional area change (FAC), right-sided index of myocardial performance (RIMP), RV ejection fraction (RVEF), tricuspid annular plane excursion by M-Mode (TAPSE), tricuspid annular systolic longitudinal velocity by tissue Doppler (S'), and regional strain and strain rate. RVEF can also be assessed volumetrically by 3D echocardiography. This article will review the current methods used in contemporary echocardiography laboratories, with an emphasis on a guideline-based approach as well as emerging techniques.
    Current Cardiology Reports 04/2015; 17(4):578. DOI:10.1007/s11886-015-0578-8
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    ABSTRACT: The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines. Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 03/2015; 28(1):1-39.e14. DOI:10.1016/j.echo.2014.10.003 · 3.99 Impact Factor
  • Lawrence G Rudski · Eduardo Bossone · David Langleben
    Chest 10/2014; 146(4):876-8. DOI:10.1378/chest.14-0856 · 7.13 Impact Factor
  • Eduardo Bossone · Lawrence G Rudski · Ekkehard Grünig
    European Heart Journal – Cardiovascular Imaging 09/2014; 15(12). DOI:10.1093/ehjci/jeu151 · 2.65 Impact Factor
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    ABSTRACT: In this article, we provide the rationale for the ELOPE (Evaluation of Long-term Outcomes after Pulmonary Embolism) Study, a prospective, observational, multicenter cohort study of patients with a newly diagnosed, first episode of pulmonary embolism (www.clinicaltrials.govNCT01174628) that aims to identify clinical, anatomic, physiologic and biomarker determinants of poor outcome after pulmonary embolism.Pulmonary embolism, the most serious form of venous thromboembolism (VTE), leads to the hospitalization or death of over 30 000 Canadians, 225 000 Americans and 300 000 Europeans each year, numbers that have risen over the past decade. Although numerous studies have evaluated optimal approaches to the diagnosis and treatment of pulmonary embolism, their focus has primarily been on short-term outcomes such as mortality and recurrent VTE in the days, weeks or months after pulmonary embolism diagnosis. However, it is increasingly recognized that pulmonary embolism may have long-lasting sequelae that impact on patients' health. The objective of this article was to review the available evidence on long-term clinical, functional, anatomic and physiologic outcomes after pulmonary embolism, and discuss avenues for research in this field, including the ELOPE Study. Residual pulmonary vascular abnormalities on follow-up imaging and echocardiogram are frequent in pulmonary embolism patients, but the clinical significance of these abnormalities is poorly understood. Whether initial and/or residual clot burden, recurrent pulmonary embolism, altered pulmonary artery or right ventricular hemodynamics or other prognostic factors such as biomarker levels contribute to long-term morbidity after pulmonary embolism is as yet unknown. The ELOPE Study will describe and identify the predictors of long-term outcomes after pulmonary embolism in the setting of a rigorous, multicenter cohort study in which long-term clinical, anatomic, physiologic and functional sequelae such as quality of life, return to work and loss of productivity after pulmonary embolism are systematically evaluated.
    Blood coagulation & fibrinolysis: an international journal in haemostasis and thrombosis 01/2014; 25(5). DOI:10.1097/MBC.0000000000000070 · 1.38 Impact Factor
  • The Canadian journal of cardiology 10/2013; 29(10):S205. DOI:10.1016/j.cjca.2013.07.335 · 3.94 Impact Factor
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    ABSTRACT: In systemic sclerosis (SSc), impaired diffusing capacity for carbon monoxide (DLCO) can indicate interstitial lung disease (ILD), pulmonary hypertension (PH), and/or other disease manifestations, including anemia. We undertook this study to compare the various measures of DLCO in the setting of a complex disease like SSc. We analyzed the pulmonary function tests of a cohort of SSc subjects, as a whole and among subjects with isolated PH and ILD separately. Associations were assessed using Spearman correlation coefficients, Student’s t tests, and F tests by one-way ANOVA. P values <0.05 were considered statistically significant. This study included 225 subjects (mean age, 57 years; 88 % women; mean disease duration, 9.6 years; 32 % with diffuse disease, 44 % with ILD, and 17 % with PH). Mean percent predicted DLCO values were 75 % for DLCOsb and 83 % for DLCOrb. Adjustment for alveolar volume (VA) resulted in near normalization of both DLCOsb/VAsb (91 %) and DLCOrb/VArb (91 %). Subjects with ILD had significantly lower DLCOsb but not DLCOsb/VAsb, whereas those with PH had significantly lower DLCOsb and DLCOsb/VAsb. Among the various measures of DLCO, DLCOsb had the strongest and most consistent associations with clinical outcomes of interest. Adjusting for alveolar volume dampened the associations except with PH, with which DLCOsb/VAsb was more strongly associated than DLCOsb. Low DLCOsb is the most sensitive measure to detect abnormalities in gas exchange in SSc but reflects both parenchymal lung disease and pulmonary vascular disease. Low DLCOsb/VAsb is more specific for pulmonary vascular disease and should be the preferred measure of gas exchange in SSc.
    Clinical Rheumatology 06/2013; 32(10). DOI:10.1007/s10067-013-2301-8 · 1.77 Impact Factor
  • Lawrence G Rudski
    Chest 06/2013; 143(6):1533-6. DOI:10.1378/chest.13-0296 · 7.13 Impact Factor
  • Lawrence G Rudski
    Chest 06/2013; 143(6):1539-40. DOI:10.1378/chest.13-0305 · 7.13 Impact Factor
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    ABSTRACT: Post-operative atrial fibrillation (AF) is a serious yet common complication after coronary artery bypass grafting surgery (CABG). Risk factors for post-operative AF have been identified, including echocardiographic parameters, and these are relied upon to implement preventative strategies that reduce the incidence of AF. There has yet to be a study examining the impact of echocardiographic right heart parameters for the prediction of post-operative AF. Thus, a panel of right heart parameters was measured in a cohort of patients undergoing isolated CABG, excluding those who did not have echocardiographic assessment within 30 days before surgery and those with any prior history of AF. The primary outcome was post-operative AF defined as any episode of AF requiring treatment during the index hospitalization. Post-operative AF occurred in 197 of 768 patients (25.6%); these were older and more likely to have hypertension and chronic kidney disease. After adjustment for clinical and echocardiographic variables, left atrial volume index ≥34 mL/m2 (OR 1.98, 95% CI 1.36 to 2.87), abnormal right ventricular myocardial performance index (RV-MPI) (OR 1.50 95% CI 1.01 to 2.24), and advancing age (OR 1.05, 95% CI 1.03 to 1.07) were found to be independent predictors of post-operative AF. In conclusion, RV-MPI is a novel predictor of post-operative AF in patients undergoing isolated CABG and appears to be additive to established risk factors such as age and left atrial volume.
    The American journal of cardiology 01/2013; 113(6). DOI:10.1016/j.amjcard.2013.11.048 · 3.43 Impact Factor
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    ABSTRACT: What is the prevalence of occult left-heart disease in patients with scleroderma (SCL) and pulmonary hypertension (PH)? In patients with PH (mean pulmonary artery pressure mPAP≥25 ;mmHg), differentiation between pre/post capillary PH has been made according to pulmonary artery wedge pressure (PAWP) less/more than15 ;mmHg, respectively.Retrospective chart review of 107 SCL-patients. All patients with suspected PH had routine right/left heart catheterization with left ventricular end-diastolic pressure (LVEDP) measurement pre/post fluid challenge. We extracted demographic, hemodynamic and echocardiographic data. Patients were classified into one of four groups - hemodynamically normal (mPAP<25 ;mmHg), pulmonary venous hypertension PVH (mPAP≥25 ;mmHg, PAWP>15 ;mmHg), occult PVH (mPAP≥25 ;mmHg, PAWP≤15 ;mmHg, LVEDP>15 ;mmHg before/after fluid challenge) and Pulmonary Arterial Hypertension PAH (mPAP≥25 ;mmHg, PAWP≤15 ;mmHg and LVEDP≤15 ;mmHg before/after fluid challenge).Fifty-three of 107 patients had PH. Based on the PAWP-based definition 29/53 had PAH and 24/53 had PVH. After considering the resting and post-fluid-challenge LVEDP, 11 PAH patients were reclassified as occult PVH. The occult PVH group was hemodynamically, echocardiographically and demographically closer to the PVH group than the PAH group.PVH had high prevalence in our SCL-PH population. Distinguishing PAH from PVH with only PAWP may result in some PVH patients being misclassified as having PAH.
    European Respiratory Journal 12/2012; 42(4). DOI:10.1183/09031936.00091212 · 7.13 Impact Factor
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    ABSTRACT: BACKGROUND: Although echocardiography is commonly performed before coronary artery bypass surgery (CABG), there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. METHODS AND RESULTS: Patients undergoing isolated CABG at two hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the STS database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction as evidenced by restrictive filling (OR 2.96; 95% CI 1.59,5.49), RV dysfunction as evidenced by fractional area change <35% (OR 3.03; 95% CI 1.28,7.20) or myocardial performance index >0.40 (OR 1.89; 95% CI 1.13,3.15). These results were confirmed in the validation cohort of 187 patients. When added to the STS risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% CI 2.8%, 8.9%). In the Cox proportional hazards model, RV dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. CONCLUSIONS: Preoperative echocardiography, in particular RV dysfunction and restrictive LV filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after CABG.
    Circulation 12/2012; 127(3). DOI:10.1161/CIRCULATIONAHA.112.127639 · 14.95 Impact Factor
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    ABSTRACT: BACKGROUND: Recent registries describe a significant prevalence of pulmonary arterial hypertension (PAH) in the elderly, but little is known of their characteristics. We aimed to examine the features and prognostic factors of long-term survival in elderly (≥65 years) PAH patients. METHODS: Clinical, echocardiographic, angiographic, hemodynamic, treatments, and survival data were reviewed in consecutive patients over the course of 20 years. Elderly PAH patients (n = 47) were compared to younger PAH patients (n = 107). RESULTS: At presentation, elderly patients were more likely to have hypertension, diabetes, dyslipidemia, coronary disease, and PAH associated with scleroderma (42.6 vs. 24.3 %; p = 0.02) than younger patients. Prior to PAH therapy, elderly patients had better right ventricular myocardial performance index (RV-MPI; 0.48 ± 0.20 vs. 0.62 ± 0.23, p = 0.006) and lower mean pulmonary arterial pressure (PAP; 45.0 ± 11.1 vs. 49.2 ± 11.8 mmHg, p = 0.04). Elderly patients were treated less often with epoprostenol (8.5 vs. 29 %, p = 0.006) or trepostinil (8.5 vs. 23.4 %, p = 0.04). The 1, 3, and 5 year survival rates of elderly patients were estimated to be 76.4, 50.5, and 37.6 %, respectively. In comparison, younger patients had survival estimates of 92.2, 74.2 and 64.0 % (p = 0.002). Baseline right atrial pressure, mean PAP, cardiac index, and RV-MPI were associated with survival in elderly patients; however in these patients, survival was not affected by any PAH subgroup or age (per year) by itself. CONCLUSIONS: The diagnosis of PAH in elderly patients is associated with poorer survival which is in part explained by a greater vulnerability to the hemodynamic disturbances of PAH.
    Beiträge zur Klinik der Tuberkulose 10/2012; 190(6). DOI:10.1007/s00408-012-9425-5 · 2.17 Impact Factor
  • Lawrence G Rudski · Jonathan Afilalo
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 07/2012; 25(7):714-7. DOI:10.1016/j.echo.2012.05.022 · 3.99 Impact Factor
  • Avi Shimony · Benjamin D Fox · David Langleben · Lawrence G Rudski
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    ABSTRACT: BACKGROUND: The incidence of pericardial effusion (PEF) during long-term follow-up among patients with pulmonary arterial hypertension (PAH) is unknown. We aimed to determine the incidence and prognostic significance of developing a new PEF among PAH patients. METHODS: Records of consecutive patients diagnosed with PAH between January 1990 and May 2010 were reviewed. Patients had systematically undergone right heart catheterization, transthoracic echocardiography, and coronary angiography during their initial assessment as well as routine echocardiograms during follow-up. Effusions were graded as small (echo-free space in diastole <10 mm), moderate (10-20 mm), or large (≥ 20 mm). RESULTS: The entire cohort consisted of 154 patients. The prevalence of identified PEF during initial assessment was 28.6%. The incidence of PEF among patients with no effusions who had additional echocardiographic studies during follow-up (n = 102) was 44.1%. Patients who developed PEF during follow-up had no differences with respect to baseline characteristics, associated aetiologies, hemodynamic parameters, and extent of coronary disease. Among these 102 patients, survival estimates were 94.9%, 75.0%, and 62.4% at 1, 3, and 5 years, respectively. Development of a PEF that was at least moderate-sized at its first appearance was a predictor of mortality in univariate (hazard ratio, 6.85; 95% confidence interval, 2.60-18.10) as well as multivariate analysis (hazard ratio, 3.95; 95% confidence interval, 1.26-12.40). CONCLUSIONS: PEF develops frequently in PAH patients. In patients with no PEF at baseline, the appearance of a new moderate-size or larger PEF is associated with increased mortality, whereas no significantly increased mortality was observed when a small PEF develops.
    The Canadian journal of cardiology 06/2012; 29(6). DOI:10.1016/j.cjca.2012.04.009 · 3.94 Impact Factor
  • Konstadina Darsaklis · Jonathan Afilalo · Lawrence G. Rudski
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    ABSTRACT: In the last decade, the role of the right ventricle (RV) has been increasingly recognized in a variety of conditions, contributing to the pathophysiology of disease and the prediction of outcomes. Recent echocardiography guidelines focused on the RV have been published by the American Society of Echocardiography to encourage a standardized approach in assessing RV size and function. In this article, we review the recently published echocardiography guidelines for assessing RV size and function, and their importance in clinical practice. We discuss advantages and disadvantages of currently available imaging techniques for evaluating the RV morphology, size, and systolic function. Basic methods such as TAPSE, tissue Doppler, RIMP, and fractional area change are discussed, as are more emerging techniques such as strain and strain rate. Additional insights are provided into upcoming uses of echocardiography in the areas or RV dyssynchrony and three-dimensional echocardiography. KeywordsEchocardiography–Right ventricle–Echocardiography - 3 dimensional–Strain imaging–Strain rate imaging–Resynchronization–Right heart
    Current Cardiovascular Imaging Reports 10/2011; 4(5):392-405. DOI:10.1007/s12410-011-9100-x
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    ABSTRACT: Guidelines for the provision of echocardiography in Canada were jointly developed and published by the Canadian Cardiovascular Society and the Canadian Society of Echocardiography in 2005. Since their publication, recognition of the importance of echocardiography to patient care has increased, along with the use of focused, point-of-care echocardiography by physicians of diverse clinical backgrounds and variable training. New guidelines for physician training and maintenance of competence in adult echocardiography were required to ensure that physicians providing either focused, point-of-care echocardiography or comprehensive echocardiography are appropriately trained and proficient in their use of echocardiography. In addition, revision of the guidelines was required to address technological advances and the desire to standardize echocardiography training across the country to facilitate the national recognition of a physician's expertise in echocardiography. This paper summarizes the new Guidelines for Physician Training and Maintenance of Competency in Adult Echocardiography, which are considerably more comprehensive than earlier guidelines and address many important issues not previously covered. These guidelines provide a blueprint for physician training despite different clinical backgrounds and help standardize physician training and training programs across the country. Adherence to the guidelines will ensure that physicians providing echocardiography have acquired sufficient expertise required for their specific practice. The document will also provide a framework for other national societies to standardize their training programs in echocardiography and will provide a benchmark by which competency in adult echocardiography may be measured.
    The Canadian journal of cardiology 07/2011; 27(6):862-4. DOI:10.1016/j.cjca.2011.03.003 · 3.94 Impact Factor