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研究生:李仁忠
研究生(外文):REN-JEN,LEE
論文名稱:在左側主幹冠狀動脈疾病病患,執行金屬支架放置手術,再發生心臟血管疾病的預測因子
論文名稱(外文):Predictors of Long-term Outcomes of Elective Stent Implantation for Unprotected Left Main Coronary Artery Disease
指導教授:施科念施科念引用關係
指導教授(外文):Ko-Nien Shih, PhD
學位類別:碩士
校院名稱:元培科學技術學院
系所名稱:影像醫學研究所
學門:醫藥衛生學門
學類:醫學技術及檢驗學類
論文種類:學術論文
論文出版年:2006
畢業學年度:94
語文別:英文
論文頁數:50
中文關鍵詞:冠狀動脈疾病左側主幹金屬支架
外文關鍵詞:left mainstentcoronary artery diseaseunprotected
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背景:
1912年Herrick發表第一例左側主幹冠狀動脈疾病病例,這份病例報告是描述一位55歲男性在做完心導管檢查之後發現左側主幹冠狀動脈有嚴重狹窄;做完檢查的52小時後因為心因性休克過世,解剖遺體發現該病患的左側主幹冠狀動脈有血栓形成導致左心室心肌大面積的壞死。之後亦有許多的臨床研究顯示左側主幹冠狀動脈疾病預後不佳的重要性。
以當時的時空背景來看,左側主幹冠狀動脈疾病的病患只能選擇藥物治療或是冠狀動脈繞道手術。Caracciolo在1995年於Circulation雜誌發表一篇CASS(Coronary Artery Surgery Study)的大規模臨床研究報告,該研究於1974-79年針對美國和加拿大地區的醫學中心的24958位冠狀動脈疾病患者進行心導管檢查,其中1484位病患屬於左側主幹冠狀動脈狹窄。這些左側主幹冠狀動脈狹窄病患中有1153位病患選擇冠狀動脈繞道手術治療,另外的351位病患選擇藥物治療;經過15年的長期追蹤發現選擇繞道手術的病患術後平均存活時間長達13.3年,而選擇藥物治療的病患平均存活時間卻僅有6.6年。
因此左側主幹的冠狀動脈疾病病患,依目前醫學共識是接受外科開刀手術治療作內乳動脈和隱靜脈的冠狀動脈繞道手術,近年來氣球擴張術曾經使用在臨床上十分緊急或者有其他疾病無法開刀的病患,然而有些病人在接受氣球擴張術後發生有急性左側支幹阻塞,甚至有許多病例有猝死的情形,所以醫療共識是不採用氣球擴張術。1978年Gruntzig發表他第一篇冠狀動脈氣球擴張術的研究報告,報告裡有一病例是左側主幹冠狀動脈的氣球擴張術;由於技術上的困難導致該病患發生心因性死亡,因此他認為左側主幹冠狀動脈疾病是氣球擴張術的禁忌症。O’Keefe-et在1989年發表一篇大規模臨床研究報告,研究結果顯示左側主幹冠狀動脈氣球擴張術初期成功率雖可達94%但有9.1%的病患在手術過程中死亡,三年存活率僅有35%。隨著衛材的進步特別是金屬支架的發明,使得急性阻塞的發生率大幅下降,於是引起了介入性心臟科醫師重新研究左側主幹冠狀動脈疾病之架置放術的臨床效果。
最近幾年冠狀動脈支架放置術也應用在某些無法接受開刀手術的左側主幹冠狀動脈疾病病患。1998年Park發表的左側主幹冠狀動脈支架置放術研究報告顯示初期成功率可達100%,在住院期間沒有病患死亡,10個月的術後追蹤發現有2%的病患死亡。由於目前的臨床研究結果仍不足以支持左側主幹冠狀動脈支架置放術對病患有絕佳的治療效果,因此對於左側主幹冠狀動脈病患接受金屬支架的預後結果,目前仍然不是十分確定。
目的:
(1) 瞭解本院左側主幹冠狀動脈疾病病患,由於病患拒絕繞道手術或者其他疾病無法進行手術,接受金屬支架置放術後,短期和長期的追蹤情形。
(2) 研究何種因子能預測病人的死亡或者重大心臟血管事件。
方法:
收集新光醫院創院以來患有左側主幹阻塞,因病人拒絕開刀或者由於其他疾病無法開刀,病人接受金屬支架置放術,以病歷記錄、門診訪談和電話訪問的方式,瞭解病人短期和長期追蹤情形,並作統計分析,瞭解何種因子能預測重大心臟血管事件或者死亡的發生。
預期效果:
瞭解本院金屬支架置放術在左側主幹阻塞疾病的治療效果,包括短期和長期的追蹤,並瞭解何種病人作金屬支架放置術後會有較高或較低的重大心臟血管事件發生。
Objectives: The purpose of this study was to investigate the predictor of long-term outcomes after stent implantation for unprotected left main coronary artery (LMCA) disease. Background: Coronary stenting has recently been advocated as an alternative procedure for LMCA disease. Information on the predictors of long-term outcomes after stent implantation for unprotected LMCA disease is not clear. Methods: Seventy six patients (51 men and 25 women, age 68  10 years) with medically refractory angina received coronary stenting for unprotected LMCA disease. During a follow-up period of 40  26 months, 23 patients (30%) needed repeated percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG). Seven patients (9%) died because of cardiovascular disease in 5 (7%) and noncardiovascular disease in 2 (3%).
Results: In a univariate analysis, only female gender was related to the repeated PCI and/or CABG (p=0.04). A history of cerebral vascular attack (CVA) (p=0.005), anemia (p=0.03) and lower left ventricular ejection fraction (LVEF) (p=0.008) were related to the cardiovascular mortality. A history of myocardial infarction (p=0.03), a history of CVA (p=0.02), anima (p=0.02) and lower LVEF (p=0.002) were related to the total mortality. In a multivariate analysis, female gender (p=0.007; odds ratio 5.29, 95% confidence interval [CI] 1.57 to 17.80) and young age (p=0.025; odds ratio 3.92, 95% CI 1.19 to 12.98) could predict the repeated PCI and/or CABG. Only a history of CVA could predict the cardiovascular mortality (p=0.027; odds ratio 34.18, 95% CI 1.49 to 783) and only lower LVEF could predict the total mortality (p=0.027; odds ratio 13.26, 95% CI 1.34 to 131). Conclusions: Female gender and young age could predict the repeated PCI and/or CABG after stent implantation for unprotected LMCA disease. Furthermore, a history of CVA could predict the cardiovascular mortality and lower LVEF could predict the total mortality.
1. Abstract
2. Introduction
3. Renerence
4. Methods
5. Stent implantation
6. Predictors of long-term Cardiovascular Outcomes
7. Statistics Analysis
8. Results Immediate and Long-term Outcomes of Stent Implantation
9. Predictors of Repeated PCI and/or CABG
10. Predictor of Cardiovascular Mortality
11. Predictor of Total Mortality
12. Discussion
 Major Findings
 Comparisons with Previous Studies
 Predictor of Repeated PCI and/or CABG
 Predictor of Cardiovascular Mortality
 Predictor of Total Mortality Disease
 Clinical Implications
13. Study Limitations
14. Conclusions
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