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J M Juliard

Publications and source records attributed to J M Juliard.

At least 37 records · Page 2Linked to original sources
PubMed1998

Incidence, consequences, and risk factors of early reocclusion after primary and/or rescue percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) achieves high patency rates. Conversely, it has been shown that after thrombolysis, early reocclusion of the infarct-related artery (IRA) is associated with substantial morbidity and mortality. The aim of this retrospective study was to study the incidence, prognostic implications, and clinical risk factors for in-hospital reocclusion of the IRA after successful emergency PTCA for AMI. We studied 399 consecutive patients (aged 59+/-14 years, 52% with anterior wall infarction) admitted <6 hours after AMI onset, of whom 374 (94%) were successfully treated with primary (n = 297) or rescue (n = 77) PTCA, with a stenting rate of 8%. Predischarge angiography was performed in 306 (82%). Early reocclusion of the IRA occurred in 28 patients (9%) and was silent in 6 (2%). The reocclusion rate was 10% for primary PTCA and 8% for rescue PTCA (p = NS). Twenty-two of 28 patients (6%) underwent repeat emergency coronary angiography because of early recurrent ischemia and most (n = 18) were treated with emergency PTCA. Early recurrent ischemia occurred mostly (86%) within 5 days of AMI onset. There was a higher prevalence of on-site hemorrhage (18% vs 5%, p = 0.007), blood transfusion (11% vs 2%, p = 0.01), pulmonary edema (21% vs 4%, p <0.01), and in-hospital death (21% vs 1%, p = 0.0001) in patients with predischarge reocclusion. On multivariate analysis, cardiogenic shock on admission and absence of dyslipidemia were strong and independent predictors (p = 0.01) of IRA reocclusion. In conclusion, early reocclusion after emergency PTCA occurred in 9% of the patients and was associated with substantial morbidity and mortality. This warrants attempts to decrease its incidence, e.g., with more frequent use of stents.

Adult↗
PubMed1998

One-month results of coronary stenting in patients > or = 75 years of age.

Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.

Aged↗
PubMed1998

Heterogeneity of prognosis in patient subsets treated by primary coronary angioplasty during acute myocardial infarction.

Among 377 patients consecutively treated with primary coronary angioplasty for acute myocardial infarction, in-hospital mortality was higher in patients ineligible than in patients eligible for thrombolysis (14.4% vs 7.8%, p <0.05). It remained dismal (75.9%) in patients with cardiogenic shock, but was similar in lytic-eligible patients and in those who were ineligible because of an increased bleeding risk (7.8% vs 7.2%, p = NS), and was zero in patients with nondiagnostic electrocardiograms.

Age Factors↗
PubMed1998

Efficacy of streptokinase, but not tissue-type plasminogen activator, in achieving 90-minute patency after thrombolysis for acute myocardial infarction decreases with time to treatment. PERM Study Group. Prospective Evaluation of Reperfusion Markers.

OBJECTIVES: We sought to examine the relation between time to treatment and 90-min patency rates in patients receiving intravenous streptokinase (SK) or accelerated tissue-type plasminogen activator (t-PA). BACKGROUND: Early patency of the infarct-related artery is a major determinant of survival after thrombolysis for acute myocardial infarction. Some data suggest that time to treatment may influence the efficacy of nonfibrin-specific thrombolytic agents in restoring early patency of the infarct-related vessel. METHODS: We performed a retrospective analysis of a cohort of 481 patients receiving thrombolytic therapy for acute myocardial infarction <6 h after pain onset, all of whom underwent 90-min coronary angiography. Patency of the infarct-related artery was graded by two observers who had no knowledge of the treatment received or the time between pain and therapy. RESULTS: There was no difference in baseline clinical or angiographic characteristics according to the timing or nature of treatment. Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 patency rate after SK correlated negatively with the time between onset of pain and thrombolysis (r = 0.8, p = 0.05), whereas the 90-min patency rate after t-PA appeared stable as a function of time to treatment. When patients were categorized as having received treatment <3 or > or = 3 h after pain onset, the patency rate was similar with t-PA, but significantly higher when SK was administered early rather than late, regardless of whether TIMI flow grades 2 and 3 were pooled (86.9% vs. 59.4%, p = 0.0001) or TIMI flow grade 3 alone was considered to indicate patency (81.7% vs. 53.6%, p = 0.0001). Multivariate logistic regression analysis showed a negative effect of time to treatment on the patency probability for SK (p = 0.0001) but not for t-PA. CONCLUSIONS: The efficacy of streptokinase but not t-PA in restoring early coronary patency after intravenous thrombolysis is markedly lower when patients are treated later after onset of pain.

Coronary Angiography↗
PubMed1998

Hospital outcome after bailout coronary stenting in patients with acute myocardial infarction.

We evaluated the outcome of bailout coronary stenting in acute myocardial infarction. Fifty patients (35 men, mean age 60 plusmn; 12) with acute myocardial infarction consecutively underwent bailout stenting after primary and rescue coronary angioplasty (n=41 and 9, respectively). Cardiogenic shock was present in six patients, and 17 others had contraindications to thrombolysis. Stent implantation was successful in 49/50 patients. The antithrombotic regimen combined heparin, aspirin, and ticlopidine. One patient had symptomatic stent closure. Predischarge angiography in 41/44 survivors showed widely patent stents in 40/41 patients. Six patients (4 of whom had been admitted with cardiogenic shock) died in the hospital. During acute myocardial infarction, bailout stenting can achieve high TIMI grade 3 coronary patency (here, 92%), and low acute stent closure rates (here, 2%). However, in-hospital mortality remained high, at nearly 10%, mainly due to the severe risk profile in this patient subset.

Adult↗
PubMed1997

Effect of the direct nitric oxide donors linsidomine and molsidomine on angiographic restenosis after coronary balloon angioplasty. The ACCORD Study. Angioplastic Coronaire Corvasal Diltiazem.

BACKGROUND: Nitric oxide (NO) donors, in addition to their vasodilator effect, decrease platelet aggregation and inhibit vascular smooth muscle cell proliferation. These actions could have beneficial effects on restenosis after coronary balloon angioplasty. METHODS AND RESULTS: In a prospective multicenter, randomized trial, 700 stable coronary patients scheduled for angioplasty received direct NO donors (infusion of linsidomine followed by oral molsidomine) or oral diltiazem. Treatment was started before angioplasty and continued until 12 to 24 hours before follow-up angiography at 6 months. The primary study end point was minimal lumen diameter, assessed by quantitative coronary angiography, 6 months after balloon angioplasty. Clinical variables were well matched in both groups. However, despite intracoronary administration of isosorbide dinitrate, the reference diameter in the NO donor group was significantly greater than in the diltiazem group on the preangioplasty, postangioplasty, and follow-up angiograms. Pretreatment with an NO donor was associated with a modest improvement in the immediate angiographic result compared with pretreatment with diltiazem (minimum luminal diameter, 1.94 versus 1.81 mm; P = .001); this improvement was maintained at the 6-month angiographic follow-up (minimal lumen diameter, 1.54 versus 1.38 mm; P = .007). The extent of late luminal narrowing did not differ significantly between groups (loss index in the NO donor and diltiazam groups, 0.35 +/- 0.78 and 0.46 +/- 0.74, respectively; P = .103). Restenosis, defined as a binary variable (> or = 50% stenosis), occurred less often in the NO donor group (38.0% versus 46.5%; P = .026). Combined major clinical events (death, nonfatal myocardial infarction, and coronary revascularization) were similar in the two groups (32.2% versus 32.4%). CONCLUSIONS: Treatment with linsidomine and molsidomine was associated with a modest improvement in the long-term angiographic result after angioplasty but had no effect on clinical outcome. The improved angiographic result related predominantly to a better immediate procedural result, because late luminal loss did not differ significantly between groups.

Aged↗
PubMed1997

Early versus late coronary stenting following acute myocardial infarction: results of the STENTIM I Study (French Registry of Stenting in Acute Myocardial Infarction).

This study was undertaken to determine the feasibility and safety of coronary stenting in acute myocardial infarction (AMI). In AMI, primary percutaneous transluminal coronary angioplasty (PTCA) is accepted as the preferred method of reperfusion for patients presenting at highly experienced centres. Until recently, however, stenting has been avoided during AMI because of a potential high risk of thrombosis. This prospective observational study carried out in 20 centres and included 648 consecutive patients who underwent PTCA with stent implantation for AMI. Of these 648 patients, 269 (41.5%, Group 1) were dilated early (< 24 hr) after the onset of the symptoms (75% treated by direct PTCA) and 379 (58.5%, Group 2) were dilated between 24 hr and 14 days after AMI. Combined therapy with ticlopidin and aspirin was used after the procedure. Bailout stenting occurred more often in Group 1 than in Group 2 (17% vs. 9.5%)(P < 0.05). Angiographic successful stenting was similar in both groups of patients (96% vs. 97%). During the hospital follow-up period, stent thrombosis occurred in eight patients (3%) in Group 1 and in six patients (1.6%) in Group 2 (NS). There was 14 deaths (5.2%) in Group 1 and 11 deaths (3.9%) in Group 2 (NS). After multivariate analysis bailout stenting was identified as the sole predictor of stent thrombosis (P < 0.0001). Vascular access-site complications occurred in six patients (1%) with no difference between the two groups. This study indicates that patients who receive a coronary stent in AMI can be managed safely with antiplatelet therapy. Randomized studies are needed to determine the precise indication for coronary stenting as an adjunct to primary PTCA.

Adult↗
PubMed1997

Conservative management of patients with acute myocardial infarction and spontaneous acute patency of the infarct-related artery.

The role of systematic emergency percutaneous transluminal coronary angioplasty (PTCA) in patients with spontaneous reperfusion during myocardial infarction is debated. We retrospectively examined the inhospital outcome of 47 consecutive patients with myocardial infarction < 6 hours and angiographically proven spontaneous patency of the infarct artery managed without initial PTCA. There was one death (2.1%) and no incidence of reinfarction. Predischarge angiography showed regression of the culprit coronary lesion to < 50% stenosis in 23% of the patients, therefore obviating the need for PTCA. However, 17% of the patients had acute recurrent ischemia, requiring emergency intervention in 10.6%. Comparison with matched patients in whom Thrombolysis in Myocardial infarction grade 3 patency was achieved by thrombolysis or by primary PTCA showed that patients with spontaneous patency tended to have smaller infarctions, as judged from a lower peak creatine kinase level (1132 +/- 1002, 2051 +/- 1536, and 2715 +/- 2146 i.u., respectively; p = 0.001) and a higher left ventricular ejection fraction (56.4%, 47.9%, and 48.7% respectively; p = 0.02). In conclusion, these patients have an excellent inhospital outcome, with evidence of less myocardial damage than in patients in whom reperfusion therapy was required to achieve TIMI 3 patency. Initial conservative treatment appears safe.

Aged↗
PubMed1997

Can we provide reperfusion therapy to all unselected patients admitted with acute myocardial infarction?

OBJECTIVES: This study sought to assess the maximal rate of acute Thrombolysis in Myocardial Infarction (TIMI) grade 3 patency that can be achieved in unselected patients. BACKGROUND: Early and complete (TIMI grade 3 flow) reperfusion is an important therapeutic goal during acute myocardial infarction. However, thrombolysis, although widely used, is often contraindicated or ineffective. The selective use of primary and rescue percutaneous transluminal coronary angioplasty (PTCA) may increase the number of patients receiving reperfusion therapy. METHODS: A cohort of 500 consecutive unselected patients with acute myocardial infarction were prospectively treated using a patency-oriented scheme: Thrombolysis-eligible patients received thrombolysis (n = 257) and underwent 90-min angiography to detect persistent occlusion for treatment with rescue PTCA. Emergency PTCA (n = 193) was attempted in patients with contraindications to thrombolysis, cardiogenic shock or uncertain diagnosis and in a subset of patients admitted under "ideal conditions." A small group of patients (n = 38) underwent acute angiography without PTCA. Conventional medical therapy was used in 12 patients with contraindications to both thrombolysis and PTCA. RESULTS: Ninety-eight percent of patients received reperfusion therapy (thrombolysis, PTCA or acute angiography), and angiographically proven early TIMI grade 3 patency was achieved in 78%. Among patients with TIMI grade 3 patency, thrombolysis alone was the strategy used in 37%, emergency PTCA in 40% and rescue PTCA after failed thrombolysis in 15%; spontaneous patency occurred in 8%. CONCLUSIONS: Reperfusion therapy can be provided to nearly every patient (98%) with acute myocardial infarction. Rescue and direct PTCA provided effective early reperfusion to patients in whom thrombolysis failed or was excluded.

Adult↗
PubMed1997

The stentless Bravo 300 aortic porcine xenograft: supra-annular versus annular implantation.

The aim of the study was to compare the supra-annular and intra-annular implantation techniques by evaluating the differences in early haemodynamic outcome (gradients, effective orifice area, regurgitation). Since August 1991, 200 stentless Bravo model 300 valves have been implanted. Patients were divided into three groups of consecutive cases: group 1 (n = 50) represents exclusively intra-annular implantation; group 2 (n = 50) is a transitional period: and group 3 (n = 100) comprises only patients with supra-annular implantation. Significant differences were found (P<0.001) in low postoperative gradients (mean < or = 10 mmHg): 24% in group 1, 42% in group 2, and 95% in group 3. Comparing groups 1 and 3, gradients were lower and effective orifice area was augmented in all valve sizes in group 3. Trivial central regurgitation was present in groups 1-3 (6%, 12% and 0% respectively). Peripheral regurgitation was trivial in 6%, 8% and 0% and mild to moderate in 4%, 2% and 0% (P<0.001).

Animals↗
PubMed1997

Sex-related differences in eligibility for reperfusion therapy and in-hospital outcome after acute myocardial infarction.

AIMS: To determine the effect of sex on reperfusion therapy and early mortality after acute myocardial infarction. METHODS: We analysed the characteristics, the reperfusion interventions, and in-hospital mortality in 400 consecutive patients (320 men and 80 women) admitted during the first 6 h of acute myocardial infarction and treated by primary angioplasty, or intravenous thrombolysis with rescue angioplasty. RESULTS: The differences between men and women were age (57 vs 67 years, P = 0.001), systemic hypertension (33 vs 50%, P = 0.02), cigarette smoking (79 vs 30%, P = 0.0001) and contraindications to thrombolysis (28.5 vs 42.5%, P = 0.02). Successful reperfusion of the infarct-related artery was achieved in 84% of patients of both sexes. In-hospital mortality was 7.2% in men and 18.7% in women (P = 0.001). Multivariate analysis was performed by linear logistic regression in order to compare several embedded models, using repeated maximum likelihood ratio tests. The best model involved the variables of cardiogenic shock and age. Addition of the variable 'sex' did not improve the predictive power of this model (P > 0.5). CONCLUSION: During acute myocardial infarction, similar successful early reperfusion rates can be achieved in men and women, despite the lower eligibility of women for thrombolytic therapy. Although in-hospital mortality was higher in women than men, the best predictive model of mortality was the combination of age and cardiogenic shock. Therefore, sex does not appear to be an independent predictor of mortality.

Aged↗
PubMed1997

A randomized trial of a fixed high dose vs a weight-adjusted low dose of intravenous heparin during coronary angioplasty.

AIMS: Prospectively to compare success rate and complications in percutaneous transluminal coronary angioplasty using two doses of heparin. METHODS AND RESULTS: Four hundred patients undergoing coronary angioplasty were randomly assigned to receive 15,000 IU (group A) or 100 IU.kg-1 (group B) of heparin. The angioplasty success rate was 95% of both groups. Stents were placed in 28.5% and 26.5% of patients in groups A and B, respectively (P = 0.73). The primary endopoint (freedom from death, myocardial infarction, unplanned revascularization or bailout stenting) occurred in 91% vs 95% of patients in groups A and B, respectively (odds ratio: 1.88, 95% CI: 0.80-4.50, P = 0.12). Haemoglobin loss was 0.36 +/- 1 and 0.27 +/- 0.9 g.dl-1 in groups A and B, respectively (P = 0.37). The time to sheath removal (735 +/- 265 vs 558 +/- 246 min) and the time to transfer to a stepdown unit (12.7 +/- 4.5 vs 9.8 +/- 4.2 h) were longer in groups A (P = 0.0001 for both comparisons). CONCLUSION: A weight-adjusted low dose of intravenous heparin is at least as safe as a fixed high dose for coronary angioplasty. It allows earlier sheath removal and discharge to a stepdown unit.

Adult↗
PubMed1997

[Orientated management towards reperfusion in the acute phase of myocardial infarction. Results in a cohort of 700 consecutive patients].

The principal objective of treatment of the acute phase of myocardial infarction is the obtention of TIMI 3 complete patency. Usually, only a minority of patients receives thrombolytic therapy and complete reperfusion in unusual. Between June 1988 and April 1996, 700 consecutive patients were admitted to Bichat hospital within 6 hours of the onset of transmural myocardial infarction (81% men; age 59 +/- 13 years). The objective of treatment was to obtain maximal coronary patency in the acute phase, either by thrombolysis (with systematic angiography at 90 minutes and salvage angioplasty in case of failure), or primary angioplasty or conventional treatment (usually in cases of spontaneous reperfusion). The emergency angiography and angioplasty procedures were performed by a medical team on 24 hour duty. During the acute phase, 316 patients received intravenous thrombolysis (angiography at 90' in 302 patients with salvage angioplasty in 79 patients), 304 underwent primary angioplasty (TIMI 3 artery in 85% of cases) and 80 underwent conventional treatment (including 52 cases of angiographically documented spontaneous reperfusion). Therefore, a 81% (566/700) rate of patent TIMI 3 arteries was obtained. The hospital mortality was 8.9%, lower in TIMI 3 arterial patency (6%) than TIMI 2 (20%) or TIMI 0-1 (23%), p < 0.001. The mortality was 4% in patients treated by thrombolysis. Therefore, a reperfusion strategy associating thrombolysis and/or angioplasty provides a high TIMI 3 patency rate in the acute phase of myocardial infarction with a low mortality (6%) in consecutive, unselected patients.

Aged↗
PubMed1997

[Urban air pollution and cardiovascular disease].

Atmospheric pollution is not considered to be a factor of cardiovascular risk in the same way as passive smoking, arterial hypertension or coronary heredity. Passive smoking is now recognised as a factor of high cardiovascular death rate and must provoke public authorities to reinforce the measures to ban smoking in public places. With regard to other pollutants, carbon monoxide, by chronic hypoxia, has been incriminated in destabilisation of high risk patients--coronary or cardiac insufficiency. The responsibility of other polluting agents on cardiovascular death rate, NO2, SO2, or O3 has not been shown clearly, because many confusing factors intervene, especially in the matter of coronary atherosclerosis.

Aged↗
PubMed1997

[Evaluation of the cost of a systematic early reperfusion of the infarction artery by primary or salvage angioplasty].

In order to evaluate the cost of a strategy designed to ensure a maximal early patency rate of the coronary artery responsible for acute myocardial infarction, we retrospectively studied 112 unselected, consecutive patients, treated during the 6 hours following onset of symptoms, either by intravenous thrombolysis (group 1, n = 57) followed by coronary angiography at the 90 th minute, and if necessary rescue angioplasty, or by primary angioplasty (group 2, n = 49), or finally by simple conventional medical treatment (group 3, contraindications to thrombolysis and catheterization, n = 6). The costs of medical treatment were expressed as standard mean costs, and were compared with total hospital expenditure. The overall hospital mortality was 8.0%: 3.5% in group 1, 8.2% in group 2, and 50% in group 3. The total cost of medical procedures during the initial hospital stay was 16,684 F, identical in groups 1 and 2 (17,985 F and 16,780 F, respectively). Total hospital expenditure was 36,254 F, with no significant difference between groups 1 and 2 (34,086 F and 41,670 F, respectively), despite a tendency towards a higher cost in group 2. This tendency reflected that of a longer hospital stay for patients in group 2, due to their more severe condition, but the proportion of medical cost within the total hospital expenditure was lower than in group 1 (40% and 53%, respectively). After one year of follow-up, only one other death from a cardiac cause was reported: the supplementary expenditure amounted to 14,617 F. This maximal reperfusion strategy during the acute phase of myocardial infarction achieved a low hospital mortality and one-year mortality, without a marked excess medical cost compared to previously published estimations. Primary angioplasty appears to have allowed a certain reduction of this cost compared to thrombolysis, but the heterogeneity of the study population does not allow direct comparison of the costs of the 2 reperfusion methods. One half of the total expenditure remains directly dependent on the duration of the hospital stay.

Angioplasty, Balloon, Coronary↗
PubMed1996

Tricuspid autograft for mitral-valve repair.

BACKGROUND: Transferring the posterior leaflet of the patient's own tricuspid valve with its subvalvular apparatus to the mitral valve is a new technique that allows a conservative approach to mitral-valve repair. The technique is based on the knowledge that the tricuspid valve can be remodelled from tricuspid to bicuspid, with a very low risk of significant dysfunction. METHODS: We describe six patients (age range 20-70 years) with mitral insufficiency in whom we have used the technique. FINDINGS: All patients survived the operation and were in sinus rhythm. Transoesophageal echocardiography before discharge showed trivial or no regurgitation at the site of mitral repair. Before operation, all patients were in New York Heart Association class III-IV; at follow-up after 6-13 months all patients were in class I-II. INTERPRETATION: Compared with using segments of mitral homografts in similar situations, the intraoperative availability of the tricuspid's viable natural chordae and valvular leaflet means that there are no immunological disadvantages to the procedure. With this new operation, the patient is his own tissue bank.

Adult↗