臺灣博碩士論文加值系統

冠狀動脈疾病（CAD）是全球死亡的第二大原因。經皮冠狀動脈介入治療（PCI）和冠狀動脈繞道移植手術（CABG）是目前CAD再血管化的主要治療方式。儘管對於具有高SYNTAX分數的複雜冠狀動脈疾病，微創傷口，身體較少傷害，早期術後恢復和早期恢復工作的需求導致PCI的廣泛使用。然而，儘管早期卒中發生率較高，但CABG在中長期隨訪中死亡率，心肌梗塞和再次介入治療的臨床效果更好。近幾十年來，隨著手術設備和技術的創新，大型開放式外科手術逐漸被內視鏡手術所取代，因為後者技術能提供較短的ICU和整體住院時間，較低的輸血需求，較少的術後併發症以及讓術後生活質量更好。機器人輔助手術是一種這樣的內視鏡手術技術，並且已經被證明是有起作用的，有效的並且在過去的幾十年中被越來越多地使用。在過去的二十年中，在全世界使用達文西 (Da Vinci) 機器人系統輔助心血管手術有著顯著的增加，該系統結合了兩種冠狀動脈血管重建方式（PCI和CABG）的優點，可提供更小的傷口，減少肋骨收縮，減輕傷口疼痛，更快術後恢復正常活動，對先天性，瓣膜性和冠狀動脈心血管病患者的生活質量產生積極影響。然而，機器人輔助冠狀動脈繞道移植手術（R-CABG）主要用於治療簡單但不復雜的CAD，因為它比傳統的冠狀動脈繞道移植手術 (C-CABG）更耗時間且術者手術技術要求更高。
因此，我們想知道在臨床實際使用下R-CABG對複雜CAD的影響，並且跟PCI或C-CABG的治療方式比較。在我的博士主題項目研究中，我們調查並比較了我們醫學中心通過三種不同的冠狀動脈血管重建方式，PCI，C-CABG和R-CABG對於治療複雜CAD患者的臨床結果。472名左主幹病變的患者中，139名患者接受R-CABG，147名患者接受C-CABG和186名患者接受PCI的治療，我們發現目標血管重建（Target vessel revascularization, TVR）指標， PCI組的 機率最高的。與其他兩組相比，R-CABG組的住院（1.4％ 對3.4％ 和9.7％，p = .0058）和隨訪全因死亡率顯著降低 ( 13.7％ 對29.3％ 和29.6％，p = .0023）。與C-CABG組患者相比，R-CABG組患者的主動脈內球囊反搏（IABP）輔助率顯著降低，ICU停留時間更短，而且全住院時間更短。然而，血管重建模式，SYNTAX分數和殘存SYNTAX分數並不是院內或長期死亡率的獨立預測因子。在另一篇638名冠狀動脈多血管疾病患者中，281名患者接受R-CABG和357名患者接受PCI的治療研究，我們發現住院和長期死亡率以及兩組間目標病變血管重建（Target lesion revascularization, TLR），心肌梗塞（myocardial infarction, MI），中風的發生率無顯著差異，但PCI組的目標血管重建 (TVR) 發生率和任何血管重建率均顯著提高。長期死亡率由年齡，左心室射血分率 (LVEF) 和慢性腎病等因子能夠預測，但血管重建方式，完全血管重建或殘存SYNTAX分數不是預測因子。後三個變項也不是長期TLR，TVR，MI或中風的預測因子。另外，516名冠狀動脈多血管疾病患者中，281名患者接受R-CABG和235名患者接受C-CABG的第三主題研究，我們發現住院和長期死亡率在R-CABG組中較低，TLR，TVR，MI和中風的發生率在兩組之間沒有顯著差異。長期死亡率與年齡，LVEF較低，慢性腎臟疾病有關，但與殘存SYNTAX分數或完整血管重建無關。血管重建模式（R-CABG與C-CABG）對於長期死亡的獨立預測處於臨界邊際。
我的博士班的主題研究表明，R-CABG在具有高SYNTAX分數的穩定左主幹疾病患者中是可行的，並且在具有較少風險因子的左主幹疾病患者中是能夠有效的替代C-CABG手術方式的治療。此外，R-CABG也是一種治療冠狀動脈多血管疾病患者的可行方式，其TVR，TLR和任何血管重建率均低於PCI，對於冠狀動脈多血管疾病有著較低外科手術風險患者可能是一種安全有效的PCI替代方案。對於臨床複雜性較低的冠狀動脈多血管疾病患者，R-CABG可能是C-CABG的有效替代方案，能夠在現實世界中提供患者較低的住院和長期死亡率。

Coronary artery disease (CAD) is the number two cause of deaths worldwide. Percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are currently the dominant modalities to revascularize CAD. The desire for minimal invasiveness, less injury, early recovery and early resumption of work have led to widespread use of PCI even for complex CAD with high SYNTAX score. However, CABG has been shown to be more effective with lower rates of mortality, MI and reintervention in the mid- and long-term follow-up despite higher early stroke rate. With innovations in surgical devices and techniques, Large open-wound surgeries have gradually been replaced by endoscopic ones in recent decades, since the latter techniques are associated with shorter ICU and total hospital stays, lower blood transfusion requirements, less post-operative complications, and better post-operative quality of life. Robot-assisted surgery is one such technique and has been proven to be effective, efficacious, and increasingly used over the past few decades. Over the past two decades, there has been a significant increase worldwide in the use of robot-assisted cardiovascular surgery using the Da Vinci system, which combines the advantages of two revascularization modalities (PCI and CABG) to provide smaller wounds, less rib retraction, reduction in pain, and faster return to normal activities with a positive impact on the quality of life in patients with congenital, valvular and coronary heart diseases. However, robot-assisted CABG (R-CABG) was mostly used for treating simple but not complex CAD because it is more time-consuming and technically demanding than conventional CABG (C-CABG).
Therefore, we would like to know the impact of R-CABG for complex CAD in comparison on PCI or C-CABG in real world practice. In my PhD program studies, we investigated and compared the clinical outcomes of complex CAD patients treated by three different revascularization approaches, PCI, C-CABG, and R-CABG, at our institute. In patients with left main disease (N=472) receiving R-CABG (n=139), C-CABG (n=147), and PCI (n=186), we found the need for target vessel revascularization (TVR) was highest in the PCI group. The R-CABG group had significantly lower in-hospital and follow-up all-cause deaths as compared with the other two groups (1.4% vs. 3.4% and 9.7%, p=.0058; 13.7% vs. 29.3% and 29.6%, p=.0023, respectively). Patients in the R-CABG group also had significantly lower rates of intra-aortic balloon pump (IABP) assistance, and shorter duration of ICU and total hospital stay compared to patients in the C-CABG group. However, revascularization modality, SYNTAX scores and residual SYNTAX scores were not independent predictors of in-hospital or long-term mortality. In another study in patients with multi-vessel CAD (N=638) who underwent R-CABG (n=281) and PCI (n= 357), treatment, we found that the in-hospital and long-term mortalities as well as the incidences for target lesion revascularization (TLR), myocardial infarction (MI), stroke were not significantly different between the two groups, but the incidence of TVR and any revascularization were significantly higher in the PCI group. The long-term mortality was predicted by age, left ventricular ejection fraction, and chronic kidney disease, but not revascularization modality, complete revascularization or residual SYNTAX score. The latter three variables were neither predictors for long-term TLR, TVR, MI, or stroke. In the third study among patients with multi-vessel CAD (N=516)who underwent R-CABG (n=281) and C-CABG (n= 235), we found that the in-hospital and long-term mortalities were lower in the R-CABG group but the incidences of TLR, TVR, MI, and stroke were not significantly different between the two groups. The long-term mortality was related to age, lower LVEF, chronic renal diseases but not residual Syntax score or completeness of revascularization. The revascularization modality (R-CABG vs C-CABG) was a borderline significant independent-predictor for long-term mortality.
My PhD program studies showed that R-CABG is feasible in stable LM disease patients with high SYNTAX scores, and is an effective alternative to C-CABG in LM disease patients with fewer risk factors. In addition, R-CABG is also a feasible modality for treating multi-vessel CAD with a lower rate of TVR, TLR and any revascularization than PCI, and might be a safe and effective alternative to PCI for patients with multi-vessel CAD and lower surgical risks. R-CABG could be an effective alternative to C-CABG for multi-vessel CAD patients with less clinical complexities, which might contribute to lower in-hospital and long-term mortalities in the real world practice.

誌謝
中文摘要 Ⅰ
英文摘要 Ⅲ
目錄 Ⅵ
圖目錄 ⅠⅩ
表目錄 ⅩⅠ
縮寫表 ⅩⅣ
第一章 前言 1
第二章 5-型磷酸二脂酶抑製劑對急性心肌缺血再灌注心肌保護作用 9
的影響
第三章 機器人輔助冠狀動脈繞道移植手術（達文西系統）相較於 18
經皮冠狀動脈介入治療應用在複雜左主幹冠狀動脈疾病的影響
第四章 機器人輔助冠狀動脈搭橋移植手術（達文西系統）相較於經皮 27
冠狀動脈介入治療應用在複雜多支血管冠狀動脈疾病的影響
第五章 結論 38
參考文獻 66
附錄 76
論文正文 77

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