Joseph Kisslo

Duke University, Durham, North Carolina, United States

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Publications (194)1335.18 Total impact

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    ABSTRACT: Background: In patients with suspected native valve infective endocarditis, current guidelines recommend initial transthoracic echocardiography (TTE) followed by transesophageal echocardiography (TEE) if clinical suspicion remains. The guidelines do not account for the quality of initial TTE or other findings that may alter the study's diagnostic characteristics. This may lead to unnecessary TEE when initial TTE was sufficient to rule out vegetation. Methods: The objective of this study was to determine if the use of a strict definition of negative results on TTE would improve the performance characteristics of TTE sufficiently to exclude vegetation. A retrospective analysis of patients at a single institution with suspected native valve endocarditis who underwent TTE followed by TEE within 7 days between January 1, 2007, and February 28, 2014, was performed. Negative results on TTE for vegetation were defined by either the standard approach (no evidence of vegetation seen on TTE) or by applying a set of strict negative criteria incorporating other findings on TTE. Using TEE as the gold standard for the presence of vegetation, the diagnostic performance of the two transthoracic approaches was compared. Results: In total, 790 pairs of TTE and TEE were identified. With the standard approach, 661 of the transthoracic studies had negative findings (no vegetation seen), compared with 104 studies with negative findings using the strict negative approach (meeting all strict negative criteria). The sensitivity and negative predictive value of TTE for detecting vegetation were substantially improved using the strict negative approach (sensitivity, 98% [95% CI, 95%-99%] vs 43% [95% CI, 36%-51%]; negative predictive value, 97% [95% CI, 92%-99%] vs 87% [95% CI, 84%-89%]). Conclusions: The ability of TTE to exclude vegetation in patients is excellent when strict criteria for negative results are applied. In patients at low to intermediate risk with strict negative results on TTE, follow-up TEE may be unnecessary.
    No preview · Article · Feb 2016 · Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography
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    ABSTRACT: Aims: We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival. Methods and results: The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001]. Conclusions: In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.
    No preview · Article · Jan 2016 · European Heart Journal
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    ABSTRACT: Background: Pediatric dilated cardiomyopathy (DCM) is associated with death or transplantation and is typically considered a homogeneous process affecting global left ventricular (LV) function. However, assessment of regional abnormalities that contribute to pumping inefficiencies is lacking. The aim of this study was to define regional strain patterns of mechanical inefficiency in the broader context of LV discoordination (dysfunction and timing abnormalities) and to evaluate their associations with LV function and clinical outcomes. Methods: Multiplanar apical LV echocardiographic images from patients with pediatric DCM (n = 56) and control subjects (n = 20) were analyzed by two-dimensional longitudinal speckle-tracking strain analysis to identify segmental strain patterns and global contraction groups. Clinical outcome (death or transplantation vs transplantation-free survival) and echocardiographic data were evaluated. Outcome groups were compared using the Fisher exact test, the χ(2) test, or analysis of variance (with P values ≤ .05 considered to indicate statistical significance). Results: Of 56 patients with DCM, 29 (52%) progressed to death or transplantation. Five segmental strain patterns were observed that were used to define seven contraction groups by regional contractility and/or timing discoordination. The group(s) with the most discoordination had the most LV dysfunction (P = .0004) and a trend toward the highest frequency of death or transplantation (P = .069). Interreader reproducibility of segmental strain patterns agreed in 165 or 180 (92%) segments tested (κ = 0.90). Control subjects had normal strain patterns. Conclusions: A heterogeneous mixture of abnormalities in the regional wall mechanics that lead to inefficient pump mechanics through functional and timing abnormalities were seen in this cohort and were categorized into natural subgroups. More severe LV discoordination was associated with increased LV dysfunction and a trend toward death or transplantation.
    No preview · Article · Dec 2015 · Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography
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    ABSTRACT: We describe an advanced real-time high-speed echocardiographic system with live display while scanning. Images are acquired at rates up to 1000 per second for adult cardiac applications and are stored in computer memory. Images may be played back in slow motion or frame by frame to analyze cardiac motion at the millisecond time scale. Images are acquired using the T5 Duke University Phased Array Scanner that allows 32:1 hardware parallel processing in receive and uses a defocused transmit beam. Clinical scans of 70 patients at rates of 240 to 1000 fps showed adequate image quality for diagnostic purpose. We anticipate that high temporal resolution cardiac images will enable the realization of more accurate and new quantitative descriptors of cardiac function in disease and health.
    No preview · Article · Oct 2015 · IEEE transactions on ultrasonics, ferroelectrics, and frequency control
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    ABSTRACT: Calcific aortic stenosis (AS) is the most common underlying pathology in patients undergoing heart valve surgery, with an expected increasing prevalence among the aging population. We identified the temporal trends in referral patterns, disease severity, and associated surgical risk among patients with AS between January 1, 1995 and December 31, 2012 at the Duke University Hospital. A total of 6103 patients had a finding of mild (n = 3303), moderate (n = 1648), or severe AS (n = 1152) in a native aortic valve. Overall presence of severe AS increased significantly over time (P = 0.009) with the most substantial increase occurring from 2010 and onward. Median age upon referral (P < 0.001) and attendant predicted surgical risk (P < 0.001) increased significantly in the observation period among patients with a finding of severe AS. Among patients with a finding of severe AS, the proportion of patients aged older than 80 years increased to 51.0% in the most recent time period (2010-2012) compared with 32.6% in the preceding time period (P < 0.001 for overall time trend). Similarly, the proportion of patients with a logistic EuroSCORE greater than 20% increased to 21.3% (2010-2012) from 12.1% (pre-2010). Among patients referred for echocardiography to a high-volume tertiary hospital center, a significant increase in the prevalence of severe AS was observed over time. This trend occurred in parallel with increasing age and predicted surgical risk at referral. Health-care resource planning should account for an increasing number of patients in need of high-risk aortic valve replacements in the near future.
    No preview · Article · Sep 2015 · Critical pathways in cardiology
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    ABSTRACT: Current guidelines suggest that patients with left bundle branch block (LBBB) be treated with cardiac resynchronization therapy (CRT); however, one-third do not have a significant activation delay, which can result in nonresponse. By identifying characteristic opposing wall contraction, 2-dimensional strain echocardiography (2DSE) may detect true LBBB activation. This study sought to investigate whether the absence of a typical LBBB mechanical activation pattern by 2DSE was associated with unfavorable long-term outcome and if this is additive to electrocardiographic (ECG) morphology and duration. From 2 centers, 208 CRT candidates (New York Heart Association classes II to IV, ejection fraction ≤35%, QRS duration ≥120 ms) with LBBB by ECG were prospectively included. Before CRT implantation, longitudinal strain in the apical 4-chamber view determined whether typical LBBB contraction was present. The pre-defined outcome was freedom from death, left ventricular assist device, or heart transplantation over 4 years. Two-thirds of patients (63%) had a typical LBBB contraction pattern. During 4 years, 48 patients (23%) reached the primary endpoint. Absence of a typical LBBB contraction was independently associated with increased risk of adverse outcome after adjustment for ischemic heart disease and QRS width (hazard ratio [HR]: 3.1; 95% CI: 1.64 to 5.88; p < 0.005). Adding pattern assessment to a risk prediction model including QRS duration and ischemic heart disease significantly improved the net reclassification index to 0.14 (p = 0.04) and improved the C-statistics (0.63 [95% CI: 0.54 to 0.72] vs. 0.71 [95% CI: 0.63 to 0.80]; p = 0.02). Use of strict LBBB ECG criteria was not independently associated with outcome in the multivariate model (HR: 1.72; 95% CI: 0.89 to 3.33; p = 0.11. Assessment of LBBB contraction pattern was superior to time-to-peak indexes of dyssynchrony (p < 0.01 for all). Contraction pattern assessment to identify true LBBB activation provided important prognostic information in CRT candidates. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Aug 2015 · Journal of the American College of Cardiology
  • Niels Risum · Joseph Kisslo · Galen Wagner

    No preview · Article · Jul 2015 · Journal of electrocardiology
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    ABSTRACT: New-onset left bundle branch block (LBBB) is a known complication during Transcatheter Aortic Valve Replacement (TAVR). This study evaluated the influence of pre-TAVR cardiac conditions on left ventricular functions in patients with new persistent LBBB post-TAVR. Only 11 patients qualified for this study because of the strict inclusion criteria. Pre-TAVR electrocardiograms were evaluated for Selvester QRS infarct score and QRS duration, and left ventricular end-systolic volume (LVESV) was used as outcome variable. There was a trend towards a positive correlation between QRS score and LVESV of r=0.59 (p=0.058), while there was no relationship between QRS duration and LVESV (r=-0.18 [p=0.59]). This study showed that patients with new LBBB and higher pre-TAVR QRS infarct score may have worse post-TAVR left ventricular function, however, pre-TAVR QRS duration has no such predictive value. Because of the small sample size these results should be interpreted with caution and assessed in a larger study population. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · May 2015 · Journal of electrocardiology
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    ABSTRACT: Left bundle branch block (LBBB) is a known complication of transcatheter aortic valve replacement (TAVR) and has been shown to predict worsened outcomes in TAVR patients. A regional longitudinal strain pattern, termed the "classic" pattern of left ventricular (LV) dyssynchrony, which is thought to be due to LBBB, is highly predictive of response to cardiac resynchronization therapy. Whether LBBB causes this "classic" pattern is not known. We retrospectively studied patients undergoing TAVR who also underwent pre- and post-TAVR strain analysis to determine if the "classic" pattern arose in those who developed TAVR-induced true LBBB. After removing patients with baseline conduction abnormalities or insufficient studies 9 patients had sufficient data for analysis. Six patients developed LBBB after TAVR and 3 patients did not develop LBBB after TAVR. ECGs were analyzed for the new onset of LBBB after TAVR. Global longitudinal strain (GLS) and regional longitudinal strain patterns were analyzed for changes between pre- and immediately post-TAVR examinations. Patients who did not develop LBBB showed no significant changes in their regional longitudinal strain pattern. Those patients who did develop LBBB showed significant increase in their difference of time-to-onset of contraction between the septal and lateral walls post-TAVR (22±14ms vs 111±49ms; p=0.003) and in their difference of time-to-peak contraction between the septal and lateral walls post-TAVR (63±56ms vs 133±46ms; p=0.002). Early lateral wall pre-stretch and delayed lateral wall peak contraction emerged in all patients with LBBB but early septal peak contraction meeting the established criteria was present in only one patient. The onset of LBBB led to acute, measurable changes in the regional longitudinal strain pattern consisting of early lateral wall pre-stretch and delayed lateral wall peak contraction. These represent 2 of the 3 findings in the "classic" pattern of LV dyssynchrony. Early termination of septal wall contraction meeting established criteria was not routinely found. Time and/or other factors may be required to develop the full "classic" pattern. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · May 2015 · Journal of electrocardiology

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Speckle-tracking strain is almost universally cited as being independent of angle of insonation, but there are minimal confirmatory studies, and this claim may not be consistent with the known limitations of ultrasound axial and lateral spatial resolution. The aim of this study was to assess the influence of angle and depth on longitudinal peak systolic strain (LPS). Thirty-four healthy pediatric subjects (age range, 6-18 years; 47% male) with normal cardiac anatomy and good image quality were prospectively imaged. Angular comparisons of LPS were investigated by examining interangle reproducibility on the basis of one standard and one alternative image acquisition relative to intraobserver reproducibility of two standard views of the same left ventricular segments. A single-window comparison was used to evaluated septal LPS: standard apical four-chamber versus right ventricular centered four-chamber. Two paired standard and alternative window comparisons were as follows: (1) four-chamber: standard apical versus subcostal; and (2) three-chamber: standard apical versus parasternal long-axis. The global LPS intraobserver difference using the paired standard and alternative window comparisons was lower than the interangle difference in global LPS (-1.0 ± 0.1% vs -2.1 ± 2.4%). Intraobserver reproducibility was significantly higher than interangle reproducibility (intraclass correlation coefficient = 0.9 vs 0.29, P < .001). Similar results were found in the segmental strain analysis. Interangle reproducibility was significantly decreased compared with intraobserver reproducibility in the septal single-window comparison. Target depth assessment demonstrated a systematic bias between the near-field and far-field segments. Echocardiographically derived LPS values were modestly dependent on angle of insonation and target depth in this pediatric population. Normal strain ranges derived from standard apical images should not be applied to strain derived from sub-costal images, off-axis apical imaging, or applications in which a standard window cannot be defined. Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Feb 2015 · Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography
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    ABSTRACT: Background: Recent studies have demonstrated that longitudinal septal deformation in patients with left ventricular (LV) dysfunction and left bundle branch block (LBBB) predict LV remodeling after CRT. However, the importance of septal deformation patterns for prediction of long-term survival is unknown. Methods: From 2 centers a total of 193 CRT candidates with LBBB (NYHA II-IV, EF≤35, and QRS≥120ms) underwent echocardiography before CRT. Longitudinal 2-D strain analysis in the apical four-chamber view identified four patterns based on previously defined criteria: double-peaked systolic pattern (type 1), early pre-ejection shortening peak followed by prominent systolic stretch (type 2), shortening with one systolic peak inside 70% of ejection phase (type 3) and normal septal peak timing outside early 70% (type 4) . Outcome was pre-defined as freedom from death, left ventricular assist device or heart transplantation over 4 years. Results: Thirty-six patients (19%) had early septal deformation pattern type 1, 49(25%) type 2, 44(23%) type 3 and 64(33%) pseudonormal septal contraction type 4. There were 35 deaths, 4 transplantations, and 6 left ventricular assist device implantations over 4 years. The event rate was 0.05% (2/36) for type 1, 14% (7/49) for type 2, 25% (11/44) for type 3, 39% (25/64) for type 4. Patients with type 1 and 2 patterns had a more favourable event-free survival HR 0.26, CI 0.09-0.81 (P=0.005) than type 3 HR 1.17, CI 0.06-2.2 (P=0.65). Patients with type 4 septal contraction showed poor event-free survival HR 2.8, CI 1.6-5.1 (<0.001). (Figure 1) Conclusions: In LBBB-patients, septal deformation strain patterns predict long-term survival after CRT. Pattern 1 and 2 are highly associated with long-term survival while patients with pattern 4 have a poor prognosis.
    Full-text · Article · Dec 2014 · European Heart Journal – Cardiovascular Imaging
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    ABSTRACT: We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
    No preview · Article · Oct 2014 · The American Journal of Cardiology
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    ABSTRACT: A new method of acquiring and displaying high speed ultrasound images has been developed. To extract flow information from the low intensity reflections of moving blood in these high frame rate images, difference imaging was found to be a particularly applicable visualization technique. Difference imaging has been shown to suppress stationary targets while increasing the contrast of the moving blood. This time domain technique has been used to visualize flow in both the left and right ventricle of the heart as well as in peripheral vasculature such as the carotid artery and hepatic blood vessels.
    No preview · Conference Paper · Sep 2014
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    ABSTRACT: BACKGROUND: Progressive heart failure leading to transplantation or death is common in pediatric dilated cardiomyopathy (DCM), and treatment options are limited. Select children with DCM have improved after cardiac resynchronization therapy (CRT), but predicting response is challenging. Nonetheless, considering the frequency of death or transplantation in this population, identifying any candidate would be valuable. Classic-pattern dyssynchrony (CPD) identifies mechanical dyssynchrony patterns consistent with underlying electrical activation delays and strongly predicts CRT response in adult DCM but has not been evaluated in pediatric DCM. The aim of this study was to test the hypothesis that CPD is present in a subgroup of patients with pediatric DCM and is associated with activation delays.
    No preview · Article · Sep 2014 · Journal of the American Society of Echocardiography
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    ABSTRACT: Background Right ventricular (RV) function is a strong predictor of mortality in pulmonary hypertension (PH), but two-dimensional (2D) echocardiography–derived assessments of RV function that could aid in risk assessment and management of patients with PH are of limited utility. RV longitudinal peak systolic strain (RVLS) derived from 2D speckle-tracking echocardiography is a relatively novel method for quantifying RV function but typically is derived from a single apical four-chamber view of the right ventricle and may have inherent limitations. The objective of this study was to determine the utility of regional and global RVLS calculated from multiple views of the right ventricle to comprehensively assess RV function in a cohort of patients with PH. Methods Regional and global RVLS were obtained from multiple views of the right ventricle (centered on the right ventricle–focused apical position) in 40 patients with PH, defined as a mean pulmonary artery pressure ≥ 25 mm Hg, most of whom also had pulmonary capillary wedge pressures ≤ 15 mm Hg and were thus defined as having pulmonary arterial hypertension. This was compared with other 2D echocardiography–derived parameters of RV function and functional parameters. Results Global RVLS calculated from multiple views had a superior correlation with 6-min walk distance compared with other parameters of RV function, including tricuspid annular plane systolic excursion, RV myocardial performance index, and fractional area change. Although global RVLS calculated from multiple views displayed a similar correlation with 6-min walk distance as global RVLS calculated from a single four-chamber view, analysis of regional strains provided by multiple views identified distinct patterns of RV dysfunction, consisting of global, free wall, or septal dysfunction, that were associated with specific clinical characteristics. Conclusions Global RVLS derived from multiple right ventricle–focused views yields a comprehensive quantitative assessment of regional and global RV function that correlates moderately with functional parameters and may be useful in the assessment of PH. Distinct patterns of regional RV dysfunction are associated with different clinical characteristics.
    Full-text · Article · Jun 2014 · Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography
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    Preview · Article · Apr 2014 · Journal of the American College of Cardiology
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    ABSTRACT: Background Although quantitative right ventricular (RV) strain analysis may be useful in congenital and acquired heart disease populations with RV failure, a comprehensive, standardized approach is lacking. An 18-segment RV strain analysis obtained from three standardized RV apical echocardiographic images was used to determine the feasibility, normal values, and reproducibility of the method in normal adults. Methods Forty healthy, prospectively enrolled volunteers with no cardiac histories and normal QRS durations underwent echocardiography optimized for strain analysis including three RV apical views. Two-dimensional speckle-tracking longitudinal strain analysis was performed using EchoPAC software. Eleven retrospectively identified subjects with RV disease were included as a pilot population. All had been imaged using the same protocol including the three RV apical views. Results All control subjects had normal anatomic morphology and function by echocardiography. Feasibility of the RV strain analysis was good (adequate tracking in 696 of 720 segments [97%]). RV global peak systolic strain was −23 ± 2%. Peak strain was highest in the RV free wall and lowest in the septum. Dyssynchrony indices demonstrated no dyssynchrony using left ventricular criteria. Reproducibility of most strain measures was acceptable. This methodology identified important disease not seen in the four-chamber apical view alone in the pilot population of 11 patients with RV disease. Strain patterns and values were different from those in the control population, indicating that differences do exist from normal. Conclusions Eighteen-segment RV strain analysis is feasible, with strain measures falling into discrete ranges in this normal population. Those with RV disease illustrate the potential utility of this approach. These data indicate that this model can be used for more detailed studies evaluating abnormal RV populations, in which its full potential can be assessed.
    No preview · Article · Apr 2014 · Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography
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    Preview · Article · Apr 2014 · Journal of the American College of Cardiology
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    Preview · Article · Apr 2014 · Journal of the American College of Cardiology

Publication Stats

5k Citations
1,335.18 Total Impact Points

Institutions

  • 1977-2015
    • Duke University
      • • Department of Medicine
      • • Department of Biomedical Engineering (BME)
      • • Department of Surgery
      Durham, North Carolina, United States
  • 1976-2015
    • Duke University Medical Center
      • • Department of Surgery
      • • Division of Cardiology
      • • Department of Medicine
      • • Department of Radiology
      • • Department of Pathology
      Durham, North Carolina, United States
  • 1984
    • California State University, Sacramento
      Sacramento, California, United States