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There are increasing rates of cardiac surgery in the elderly. Frailty, depression, and social vulnerability are frequently present in older people, and should be considered while assessing risk and providing treatment options. We aimed to analyse the impact of clinically relevant variables on survival at one year, and identify areas of future intervention. We performed a prospective cohort study at a University Hospital, with a sample of 309 elective cardiac surgery patients 65 years old and over. Their socio-demographic and clinical variables were collected. Frailty prevalence was 61.3%, while depression was absent in the majority of patients. Mortality was 1.6% and 7.8% at 30 days and 12 months, respectively. After Kaplan-Meier analysis, severe frailty (p = 0.003), severe depression (p = 0.027), pneumonia until 30 days (p = 0.014), and re-operation until 12 months (p = 0.003) significantly reduced survival, while social support increased survival (p = 0.004). In the adjusted multivariable Cox regression model, EuroSCORE II (HR = 1.27 [95% CI 1.069-1.499] p = 0.006), pneumonia until 30 days (HR = 4.19 [95% CI 1.169-15.034] p = 0.028), re-intervention until 12 months (HR = 3.14 [95% CI 1.091-9.056] p = 0.034), and social support (HR = 0.24 [95% CI 0.079-0.727] p = 0.012) explained time until death. Regular screening for social support, depression, and frailty adds relevant information regarding risk stratification, perioperative interventions, and decision-making in older people considered for cardiac surgery.

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INTRODUCTION: Frailty is a multidimensional syndrome characterized by the loss of functional reserve, associated with higher mortality and less functional survival in cardiac surgery patients. The Edmonton Frail Scale (EFS) is a comprehensive tool devised for brief frailty detection. To the best of our knowledge, there are no culturally adapted and validated frailty screening tools that enable the identification of vulnerability domains suited for use in the preoperative setting in Portugal. This was the motivation for this study. OBJECTIVES: To assess the validity and reproducibility of the Portuguese version of the EFS. METHODS: Prospective observational study, in a sample of elective cardiac surgery patients. The Edmonton Frail Scale (EFS) translation and backtranslation were performed. Demographic and clinical data were collected, and the translated EFS translated, Geriatric Depression Scale, and Mini Mental State Examination Portuguese versions, Katz and Clinical Frailty Scales were administered. To assess validity Mann-Whitney test, Spearman's correlation coefficient, marginal homogeneity test and Kappa coefficient were employed. Reproducibility was assessed estimating kappa coefficient for the frailty diagnosis and the 11 EFS items. Intra-class correlation coefficients and the corresponding 95% confidence interval were estimated using linear mixed effects model. RESULTS: The EFS Portuguese version revealed construct validity for frailty identification, as well as criterion validity for cognition and mood domains. Reproducibility was demonstrated, with k=0.62 (95% confidence interval (CI) 0.42-0.82) and intraclass correlation (ICC)=0.94 (95% CI 0.89-0.97) in inter-observer test and k=0.48 (95% CI 0.26-0.70) and ICC=0.85 (95% CI 0.72-0.92) in intra-observer test. CONCLUSIONS: The EFS Portuguese version is valid and reproducible for use, suiting pre-operative frailty screening in a cardiac surgery setting.

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OBJECTIVE: The preoperative factors determining the selection of anesthetic technique in patients submitted to TAVI were identified. The results of this procedure in our hospital were evaluated. METHODS: Retrospective study in patients submitted to TAVI in Santa Marta Hospital (January 2010 to December 2016). Data collected from periprocedural records and stratified according to the anesthetic technique. Periprocedural complications were defined according to The Valve Academic Research Consortium 2. The preoperative factors determining the selection of anesthetic technique were identified through Chi-square test (categorical variables) and Student's t tests (continuous variables), followed by logistic regression. RESULTS: Bad vascular access identified by TC was a preoperative determinant for general anesthesia selection. Arterial hypertension and previous acute myocardial infarction were determinants for selection of local anesthesia with sedation. From a total of 149 patients, 105 (70,5%) developed some postprocedural complication; the most common were arrhythmias (n=53; 35,6%), major bleeding (n=50; 33,6%) and vascular complications (n=36; 24,2%). CONCLUSION: There is no consensus regarding the best anesthetic technique to be performed in patients submitted to TAVI. It is the anesthesiologist decision which most appropriate anesthetic technique to select, considering technical aspects and objective evaluation of the patient. Local anesthesia with sedation showed some advantages: shorter duration of procedure and fewer patients requiring vasopressor drugs administration. TAVI is a highly complex procedure and a multidisciplinary approach is fundamental to its success.

Objetivo: Foram identificados fatores pré-operatórios relacionados com o doente, determinantes para seleção da técnica anestésica em doentes submetidos a TAVI, e avaliados os resultados deste tipo de intervenção no nosso centro. Métodos: Estudo retrospetivo em doentes submetidos a TAVI no Hospital de Santa Marta (Janeiro de 2010 a Dezembro de 2016). Dados colhidos a partir dos registos peri- procedimento, e estratificados de acordo com a técnica anestésica. As complicações periprocedimento foram definidas de acordo com The Valve Academic Research Consortium-2. Os fatores pré-operatórios determinantes para a seleção da técnica anestésica foram identificados com os testes Qui-quadrado (variáveis categóricas) e t de Student (variáveis contínuas), e posterior regressão logística. Resultados: Os maus acessos vasculares definidos por TAC foram o fator pré-operatório determinante para a seleção de anestesia geral. A hipertensão arterial e a ocorrência de enfarte agudo do miocárdio prévio foram determinantes da escolha da anestesia local com sedação. Dos 149 doentes, 105 (70,5%) desenvolveram alguma complicação pós-operatória, sendo as mais comuns as arritmias cardíacas (n=53; 35,6%), perdas sanguíneas major (n=50; 33,6%) e as complicações vasculares (n=36; 24,2%). Conclusão: Não existindo consenso quanto à melhor técnica anestésica a realizar para a TAVI, cabe ao anestesiologista a seleção da técnica mais adequada, tendo em conta aspectos técnicos e a avaliação objetiva do doente. A anestesia local com sedação mostra alguns benefícios: menor duração do procedimento e um menor número de doentes a requerer a administração de fármacos vasopressores. A TAVI apresenta elevada complexidade, sendo a abordagem multidisciplinar fundamental para o seu sucesso.

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INTRODUCTION: Spinal cord ischemia (SCI) and the resulting paraplegia are one of the most feared postoperative complications after thoraco-abdominal aortic surgery, with an incidence 4,3-8,0% after thoracic endovascular aortic repair (TEVAR), increasing patients morbi-mortality. Lumbar cerebrospinal fluid (CSF) drainage catheter is recommended as preventive measure in high risk patients. OBJECTIVE: To evaluate the efficiency and safety of CSF drainage catheter as preventive or therapeutic measure in endovascular aortic repair (EAR). METHODS: Retrospective study in 19 patients submitted to TEVAR or fEVAR (fenestrated endovascular aneurism repair), in whom CSF drainage catheter was used, between January 2010 and March 2017. Collected data regarding demographic, perioperative patients characteristics, neurologic symptoms (NS) and other complications. All patients were submitted to general anesthesia (GA) as result of complexity and length of surgery. Known risk factors (RF) for SCI were taken into account. RESULTS: 19 patients, 89,5% (n=17) male, mean age of 66±9 years. 63,2% were classified as ASA III and 36,8% as ASA IV. 9 patients submitted to TEVAR (47,4%); the remaining were submitted to fEVAR. 73,7 % were programed procedures. There were intraoperative complications in 3 patients: iliac artery (IA) rupture in 2 patients, laceration of the axillary artery in 1 patient, all required surgical repair. All catheters were placed in awake patients, before GA induction, and were left in place 2,5 days. 7 patients needed drainage because of CSF pressure>10mmHg intra- or postoperatively. 3 patients developed early symptoms of SCI (decreased mobility and strength of legs). Complete recovery occurred in all patients, except one who recovered just partially. 1 patient developed late NS: paraparesia on 40th postoperative day (POD) as result of spinal stroke. 30 days mortality was 10,5% (n=2), due to cardiorespiratory arrest- 1 by hypovolemic shock (on 3rd POD), 1 by unknown cause (14th POD). CONCLUSION: This study was limited by the small sample size. CSF drainage catheter was an efficient measure in prevention and treatment of SCI in this sample, since there was no case of complications due to SCI. CSF drainage seems to be an effective technique in preventing SCI. Further studies are required to determine the effectiveness and compare the different methods available for the prevention of SCI complications.

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Negative pressure pulmonary oedema is an uncommon complication of traqueal extubation (approximately 0,1%) mostly caused by acute upper airway obstruction. Upper airway obstruction from glottis closure leads to marked inspiratory effort, which generates negative intrathoracic pressure transmitting to pulmonary interstitium, and inducing fluid transudation from pulmonary capillary bed(1-5). We report a case of post-extubation pulmonary oedema in a fifteen years old patient, submitted to surgery following traumatic amputation of his left leg. We review the pathophysiology, radiological findings, potential risk factors and preventive measures of this post-anaesthetic respiratory complication.

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