Lawrence G Rudski

McGill University, Montréal, Quebec, Canada

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Publications (22)110.2 Total impact

  • Journal of the American Heart Association 10/2015; 4(10):e002129. DOI:10.1161/JAHA.115.002129 · 4.31 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 · 5.32 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 · 3.05 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 · 1.93 Impact Factor
  • Lawrence G Rudski · Eduardo Bossone · David Langleben ·

    Chest 10/2014; 146(4):876-8. DOI:10.1378/chest.14-0856 · 7.48 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
  • J. Afilalo · L.G. Rudski · M.H. Picard · Y. Langlois · F. Ma · J. Morin · D.M. Shahian ·

    The Canadian journal of cardiology 10/2013; 29(10):S205. DOI:10.1016/j.cjca.2013.07.335 · 3.71 Impact Factor
  • Lawrence G Rudski ·

    Chest 06/2013; 143(6):1533-6. DOI:10.1378/chest.13-0296 · 7.48 Impact Factor
  • Lawrence G Rudski ·

    Chest 06/2013; 143(6):1539-40. DOI:10.1378/chest.13-0305 · 7.48 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 · 3.28 Impact Factor
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    ABSTRACT: Background: Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. Methods and results: Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons 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 (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons 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% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. Conclusions: Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.
    Circulation 12/2012; 127(3). DOI:10.1161/CIRCULATIONAHA.112.127639 · 14.43 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 · 2.27 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 · 4.06 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
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    ABSTRACT: The occurrence and impact of coronary artery disease (CAD) among patients with pulmonary arterial hypertension (PAH) are unknown. We aimed to determine the prevalence, clinical correlates, and effect of CAD in patients with PAH. We reviewed the medical records of consecutive patients diagnosed with PAH at a university-based referral center for pulmonary vascular disease from January 1990 to May 2010. The patients systematically underwent right heart catheterization and coronary angiography as a part of their evaluation. The patients with PAH with CAD (defined as ≥50% stenosis in ≥1 major epicardial coronary artery) were compared to patients without CAD. Among the 162 patients with PAH, the prevalence of CAD was 28.4%. The presence of CAD was associated with older age (66.6 ± 11.5 vs 49.2 ± 14.0 years, p <0.001), systemic hypertension, and dyslipidemia. The patients with PAH and CAD had a lower mean pulmonary arterial pressure (44.6 ± 11.1 vs 49.2 ± 14.0 mm Hg; p = 0.02) than patients without CAD. During a median follow-up of 36 months, 73 patients died. The presence of CAD was a predictor of all-cause mortality on univariate analysis (hazard ratio 1.97, 95% confidence interval 1.21 to 3.20) but not on multivariate analysis, which identified older age (hazard ratio 1.03, 95% confidence interval 1.01 to 1.05) and right atrial pressure (hazard ratio 1.08, 95% confidence interval 1.03 to 1.14) as the only independent predictors. In conclusion, our study has demonstrated that CAD is common among patients with PAH. CAD prevalence increases with age, dyslipidemia, and hypertension, but we did not detect an independent prognostic effect of CAD on mortality.
    The American journal of cardiology 05/2011; 108(3):460-4. DOI:10.1016/j.amjcard.2011.03.066 · 3.28 Impact Factor
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    Journal of the American College of Cardiology 04/2011; 57(14). DOI:10.1016/S0735-1097(11)61010-3 · 16.50 Impact Factor
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    ABSTRACT: The right ventricle plays an important role in the morbidity and mortality of patients presenting with signs and symptoms of cardiopulmonary disease. However, the systematic assessment of right heart function is not uniformly carried out. This is due partly to the enormous attention given to the evaluation of the left heart, a lack of familiarity with ultrasound techniques that can be used in imaging the right heart, and a paucity of ultrasound studies providing normal reference values of right heart size and function. In all studies, the sonographer and physician should examine the right heart using multiple acoustic windows, and the report should represent an assessment based on qualitative and quantitative parameters. The parameters to be performed and reported should include a measure of right ventricular (RV) size, right atrial (RA) size, RV systolic function (at least one of the following: fractional area change [FAC], S′, and tricuspid annular plane systolic excursion [TAPSE]; with or without RV index of myocardial performance [RIMP]), and systolic pulmonary artery (PA) pressure (SPAP) with estimate of RA pressure on the basis of inferior vena cava (IVC) size and collapse. In many conditions, additional measures such as PA diastolic pressure (PADP) and an assessment of RV diastolic function are indicated. The reference values for these recommended measurements are displayed in Table 1. These reference values are based on values obtained from normal individuals without any histories of heart disease and exclude those with histories of congenital heart disease. Many of the recommended values differ from those published in the previous recommendations for chamber quantification of the American Society of Echocardiography (ASE). The current values are based on larger populations or pooled values from several studies, while several previous normal values were based on a single study. It is important for the interpreting physician to recognize that the values proposed are not indexed to body surface area or height. As a result, it is possible that patients at either extreme may be misclassified as having values outside the reference ranges. The available data are insufficient for the classification of the abnormal categories into mild, moderate, and severe. Interpreters should therefore use their judgment in determining the extent of abnormality observed for any given parameter. As in all studies, it is therefore critical that all information obtained from the echocardiographic examination be considered in the final interpretation. Essential Imaging Windows and Views: Apical 4-chamber, modified apical 4-chamber, left parasternal long-axis (PLAX) and parasternal short-axis (PSAX), left parasternal RV inflow, and subcostal views provide images for the comprehensive assessment of RV systolic and diastolic function and RV systolic pressure (RVSP).
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 07/2010; 23(7):685-713; quiz 786-8. DOI:10.1016/j.echo.2010.05.010 · 4.06 Impact Factor
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    ABSTRACT: Clinical outcomes and echocardiographic parameters associated with aortic valve replacement (AVR) for bicuspid aortic valve are scarce. We conducted retrospective analysis of 208 adults with bicuspid aortic valve referred for transthoracic echocardiograms. The Kaplan-Meier survival free of death or need for cardiac surgery was 72% at 5 years. Cardiac surgery was performed in 19%, the majority (68%) for symptomatic aortic stenosis. Peak gradient 80 mm Hg or greater (hazard ratio 11.8, 95% confidence interval 3.7-37.8, P < .0001) and aortic valve area less than or equal to 0.75 cm(2) (hazard ratio 2.9, 95% confidence interval 1.0-8.5, P = .05) predicted the need for AVR. Patients with a large (54%) versus normal left ventricular outflow tract dimension underwent AVR for symptomatic aortic stenosis at a larger calculated aortic valve area (1.07 +/- 0.21 vs 0.75 +/- 0.18 cm(2), P < .0001) but at a similar peak gradient and velocity ratio (76 +/- 19 vs 76 +/- 22 mm Hg, P = not significant; 0.23 +/- 0.06 vs 0.26 +/- 0.12, P = not significant, respectively). Clinical events are common among patients with bicuspid aortic valve. Peak gradient 80 mm Hg or more and aortic valve area less than or equal to 0.75 cm(2) predicts the need for AVR. Gradients and velocity ratio better reflect the hemodynamic burden of aortic stenosis in patients with a large left ventricular outflow tract.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 08/2007; 20(8):998-1003. DOI:10.1016/j.echo.2007.01.003 · 4.06 Impact Factor