الفهرس 
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Abstract
Myocardial protection during minimally invasive cardiac surgery has never been specifically studied, maybe because other aspects – such as technical and technological adjustments - of this relatively new kind of surgery were considered more important; moreover, the Custodiol cardioplegia seemed to guarantee excellent results. As in the minimally invasive setting, a single-shot, long-lasting dose of crystalloid cardioplegia is definitely straightforward and less time-consuming; therefore, crystalloid solutions are largely preferred.
This non-randomizes clinical trial included 82 patients with valve lesions underwent Minimally invasive cardiac surgery (MICS), dconducted on El-Galaa military medical complex and cardiothoracic surgery academy, Faculty of Medicine, Ein Shams University. The study design was approved by Ain Shams Faculty of Medicine’s Ethical Committee.
All 82 patients were categorized into two groups:
• Cold crystalloid (Custodiol) group (n=41): Patients who underwent cold crystalloid (Custodiol) cardioplegia.
• Cold blood group (n=41): Patients who underwent Cold blood cardioplegia.
The following was carried out for each subject:
• Full history: Personal data, and Co-morbidities.
• Investigations: Laboratory findings and ECHO.
• Outcomes: ICU stay duration, ventilation and duration, and incidence of AF.
Regarding sociodemographic characteristics of included patients, the mean age was 58.1 ± 5.15 yrs old for cold blood group and 52.05 ± 10.41 yrs old for cold crystalloid (Custodiol) group with statistical significant (p=0.001). While male patients were predominance in both groups (68.3% of patients who received cold crystalloid (Custodiol) and 51.2% of patients who received cold blood) with insignificant difference (p=0.176). There was no significant difference between both groups concerning their mean weights and heights (83.77 ± 14.32 vs 83.17 ± 4.99) for weights and (168.27 ± 21.72 vs 173.78 ± 5.62) for heights respectively with no statistical difference (p=0.802, p=0.123) respectively.
Concerning preoperative parameters, the current study found that their preoperative hemoglobin levels were slightly higher among patients within Cold crystalloid (Custodiol) group when compared to the other group (13.34 ± 1.29 vs 12.81 ± 0.94) mg/dl with statistical significant (p=0.036). Also there was a significant increase in serum levels of INR among patients within cold crystalloid (Custodiol) group when compared to others (1.12 ± 0.12 vs 1.06 ± 0.07) respectively with significant difference (p=0.004). While, serum creatinine levels were slightly higher among patients within Cold blood group when compared to others (1.16 ± 0.09 vs 1.14 ± 0.21) with insignificant difference (p=0.618). On the other hand, we found that patients within Cold crystalloid (Custodiol) group had significantly elevated serum levels of Ck-mb when compared to others (14.54 ± 4.11 vs 9.68 ± 1.13) (<0.001). Also there was significant increase in their Ejection fraction among patients within cold crystalloid (Custodiol) group when compared to others (59.71 ± 6.92 vs 53.68 ± 3.53)%t (p<0.001). Regarding comorbidities, no significant difference between two groups regarding asthma, DM, HTN and smoking (P 0.0743).
Regarding their 8h postoperative CK-mb, there was a slight increase in serum levels of CK-mb among patients within cold blood group when compared to others (58.68 ± 14.39 vs 57.34 ± 35.49) respectively. This was statistically insignificant (p=0.823).On the other hand, their 24h postoperative CK-mb serum levels were slightly higher among patients within Cold crystalloid (Custodiol) group when compared to others (43.17 ± 36.17 vs 40.32 ± 10.02 with insignificant difference(p=0.629).After 48 h, we found that patients within Cold crystalloid (Custodiol) group had insignificantly lower serum levels of Ck-mb when compared to others (26.83 ± 17.72 vs 29.88 ± 8.24) (p=0.322).
Regarding postoperative Ejection fraction, after 24 h, there was a slight increase in postoperative EF among those with Cold crystalloid (Custodiol) group when compared to the other group (50.59 ± 7.57 vs 48.24 ± 3.58) with insignificant difference (p=0.079). Similarly, there was a significant increase in post operative EF after 48 hours postoperative among those within Cold crystalloid (Custodiol) group when compared to others (55.56 ± 6.88 vs 51.2 ±3.36) respectively(p=0.001).
With reference to change in operative parameters (CK-mb), among crystalloid group, there was a sharp increase in serum levels of CK-mb from preoperative to the first 8 hours of postoperative period from 12.11 ± 3.87 to 58.01 ± 26.93 respectively. This gradually decreased to reach 41.74 ± 26.41 after 24 hours of postoperative period. in addition, that decrease continued to reach 28.35 ± 13.82 after 48 hours of operation. This was statistically significant (p<0.001).
Regarding change in operative parameters (Ejection fraction (EF), There was a sharp decrease among patients in the cold crystalloid (Custodiol) in EF from preoperative to the first 24 hours of postoperative period from 59.71 ± 6.92 to 50.59 ± 7.57 respectively. This gradually increased to reach 55.56 ± 6.88 after 48 hours of postoperative period. This was statistically significant (p<0.001). Similarly, among patients within cold blood group, we found there was a sharp decrease in the EF from 53.68 ± 3.53 to 48.24 ± 3.58 after 24 hours. This gradually increased to reach 51.2 ± 3.36 after 48 hours of operation.
As regard intra-operative data, no significant difference between two groups regarding CCT, while there was significant increase of TBT in cold blood group, in comparison to cold crystalloid (Custodiol) group (P.0.008).
Regarding TEE, there was no significant difference of pre TEE between two groups (p.0.069), while there was significant increases of post TEE [ejection fraction (EF)] in cold crystalloid (Custodiol) group in comparison to cold blood group (P.0.001).
Concerning post operative complications, Only 9.8% of patients within Cold crystalloid (Custodiol) group developed postoperative AF. This was significantly lower than those within the cold blood group among whom 51.2% of patients developed postoperative AF with significant difference (p<0.001). Similarly, the total hospital stay duration was significantly lower among patients within cold crystalloid (Custodiol) group compared to the other group (7.83 ± 1.2 vs 8.83 ± 1.49) days respectively with significant difference (p=0.001). On the other hand, patients within Cold blood group needed less ventilation duration compared to the other group (6.61 ± 1.59 vs 6.71 ± 2.11) with insignificant difference (p=0.814).