IJCS | Volume 31, Nº5, September / October 2018

480 Oliveira et al. Mortality and survival in aortic arch surgeries Int J Cardiovasc Sci. 2018;31(5)466-482 Original Article Previous arrhythmia: ( ) yes ( ) no ( ) NI Specified: ( ) yes ( ) no ( ) NI ECG in the records: ( ) yes ( ) no ( ) Which one ___________________ PM: ( ) yes ( ) no ( ) temporary ( ) permanent Previous AMI: ( ) yes ( ) no ( ) NI How long ago _________________ ( ) NI (days/weeks/years/NI) Unstable angina: ( ) yes ( ) no ( ) NI Heart failure: ( ) yes ( ) no ( ) NI NYHA HF: ( ) I ( ) II ( ) III ( ) IV ( ) NI Mod/Severe valve failure: 1. Mitral: ( ) yes ( ) no ( ) NI 2. Aortic: ( ) yes ( ) no ( ) NI 3. Tricuspid : ( ) yes ( ) no ( ) NI Mod/Severe valve stenosis: 1. Mitral: ( ) yes ( ) no ( ) NI 2. Aortic: ( ) yes ( ) no ( ) NI 3. Tricuspid : ( ) yes ( ) no ( ) NI Extracardiac vascular disease Claudication: ( ) yes ( ) no ( ) NI Carotid artery occlusion or stenosis > 50%: ( ) yes ( ) no ( ) NI Amputation for vascular disease: ( ) yes ( ) no ( ) NI Abdominal aortic, iliac or carotid arterial intervention: ( ) yes ( ) no ( ) NI Active endocarditis: ( ) yes ( ) no ( ) NI Previous surgeries Myocardial revascularization: ( ) yes ( ) no ( ) NI Valve replacement: ( ) yes ( ) no ( ) NI Partial aortic arch replacement: ( ) yes ( ) no ( ) NI Structural repair/tumor resection: ( ) yes ( ) no ( ) NI Aortic dissection (Stanford classification) Type A: ( ) yes ( ) no ( ) NI Type B: ( ) yes ( ) no ( ) NI Aortic arch aneurysm: ( ) yes ( ) no ( ) NI Ascending aortic aneurysm: ( ) yes ( ) no ( ) NI 3. Echocardiographic data Echocardiography test: ( ) yes ( ) no ( ) NI Date: ______/______/__________ Ejection fraction __________ ( ) NI LVd: __________ ( ) NI SIV: __________ ( ) NI VDs: __________ ( ) NI PP: __________ ( ) NI LVH: __________ ( ) NI LA: __________ ( ) NI PASP: __________ ( ) NI Functional subjective assessment LV systolic function: ( ) normal ( ) mild disf. ( ) Mod disf. ( ) Severe disf. ( ) NI LV diastolic function: ( ) normal ( ) mild disf. ( ) Mod disf. ( ) Severe disf. ( ) NI RV: ( ) normal ( ) mild disf. ( ) Mod disf. ( ) Severe disf. ( ) NI Pericardial effusion: ( ) yes ( ) no ( ) NI