Form 1RL: Relisting - UAB
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Calculated BSA: n/a BMI: n/a Patient Details Hidden Show Show/Hide Annotations Height and Weight Form 1RL: Relisting Not Started Print this Form 1 Date of Relisting 2 Height Centimeters Inches Missing Reason: Not Done Unknown 3 Weight Kilograms Pounds Missing Reason: Not Done Unknown 4 Has this patient been transplanted No Yes 4 Indicate total number of prior transplants This includes transplants that were and were not done at your hospital. Missing Reason: Unknown 5 Main reason for ReListing Coronary artery disease, (infarction, arrhythmia, CHF post MI) NonSpecific Graft Failure (>30 days post transplant) Pulmonary Hypertension/RV Failure Rejection, acute Rejection Hyperacute (onset < 24 hours post transplant) Rejection, Acute Sudden Cardiac Death, no MI documented Other, specify 6 Contributing reason for ReListing Coronary artery disease, (infarction, arrhythmia, CHF post MI) Noncompliance Nonspecific graft failure (>30 days post transplant)
Transcript of Form 1RL: Relisting - UAB
Calculated
BSA: n/a BMI: n/a
Patient Details Hidden ShowShow/Hide Annotations
Height and Weight
Form 1RL: Relisting Not StartedPrint this Form
1 Date of Relisting
2 Height Centimeters Inches
Missing Reason: Not Done Unknown
3 Weight Kilograms Pounds
Missing Reason: Not Done Unknown
4 Has this patient been transplanted NoYes
4 Indicate total number of priortransplants
This includes transplants that were and were not done atyour hospital.
Missing Reason: Unknown
5Main reason for ReListing Coronary artery disease, (infarction, arrhythmia,
CHF post MI)NonSpecific Graft Failure (>30 days posttransplant)Pulmonary Hypertension/RV Failure Rejection,acuteRejection Hyperacute (onset < 24 hours posttransplant)Rejection, AcuteSudden Cardiac Death, no MI documentedOther, specify
6 Contributing reason for ReListing Coronary artery disease, (infarction, arrhythmia,CHF post MI)NoncomplianceNonspecific graft failure (>30 days post transplant)
Status Details at ReListing
Pulmonary Hypertension/RV FailureRejection, acuteRejection, hyperacute (onset < 24 hours posttransplant)Sudden cardiac death, no MI documentedOther, specify
7 Status at ReListing BrazilCanadaUnited KingdomUnited States
7a Status at ReListing, US 1 (this option is only for listings prior to 1999)1A1B27
7aStatus at ReListing, Canada 0
1233.54
7a Status at ReListing, UK RoutineUrgent
7a Status at ReListing, Brazil NonPriorityPriority
7b Was patient in or out of hospitalat time of listing?
In hospitalOut of hospital
7b.i Was patient in the ICU attime of relisting?
NoYesUnknown
7b.ii Did the patient requirecontinuous invasive
mechanical ventilation?
NoYesUnknown
7c Did the patient requirecontinuous inotropes at time of
listing?
YesNoUnknown
Infectious Disease Screening
7c.i Inotropes does Dose UnknownHigh Dose or Multiple IVSingle Low Dose
7d Did the patient have ductaldependent pulmonary or
systemic circulation, with ductalpatency maintained by stent or
prostaglandin infusion?
YesNoUnknown
7e ABO incompatible NoYesUnknown
7f Was patient on a VAD or ECMO attime of relisting?
VADECMONot on support at time of Relisting
7f Specify initiation date (VAD) Missing Reason: Unknown
7f Specify initiation date (ECMO) Missing Reason: Unknown
7g Was patient listed for DCD(Donation after Cardiac Death)
organ?
YesNoUnknownThis is not current practice at our center
8 HIV Serology AIDS testing
Negative Not Done Positive Unknown
8 CMV Serology Negative Not Done Positive Unknown
8 CMV PCR Negative Not Done Positive Unknown
8 EBV Serology Negative Not Done Positive Unknown
8EBV PCR Negative Not Done Positive
Unknown
8 IFA Toxo Toxoplasma testing
Negative Not Done Positive Unknown
Negative Not Done Positive
Medical History at time of ReListing
8 HBs Ag Hepatitis B surface antigen
Unknown
8 HB core Ab Hepatitis B core antibody
Negative Not Done Positive Unknown
8 HBs Ab Hepatitis B surface antibody
Negative Not Done Positive Unknown
8 Hep C Ab Hepatitis C antibody
Negative Not Done Positive Unknown
8 RPR/Syphilis Syphilis testing
Negative Not Done Positive Unknown
9 Medical History NoYesUnknown
9 Medical History Details Select all medical history the patient had at the time of
listing.
Arrhythmia (current heart only)Cardiac arrest/CPR (current heart)DiabetesGI/NutritionHeterotaxy/IsomerismMalignancyMetabolic DisorderMitochondrial DisorderNeurologicalPacemaker (current heart)Peripheral myopathy/neuromuscular diseasePrenatal DiagnosisPrior transfusionsRenal insufficencyRespiratoryShock (current heart)SyndromeOther, specify
9 Arrhythmia Afib/flutterComplete heart blockV FibrilliationV TachycardiaUnknownOther, specify
9Date of last cardiac arrest/CPR MM/DD/YYYY
Missing Reason: Unknown
9 Pacemaker Defibrillator/AICDPacemaker, CRT/Biventricular pacing
Pacemaker, not CRT and not ICD
9 Pacemaker, not CRT and not ICD,
Date placed MM/DD/YYYY
Missing Reason: Unknown
9 Pacemaker, CRT/Biventricular pacing
Date placed MM/DD/YYYY
Missing Reason: Unknown
9 Defibrillator/AICD, Date Placed
MM/DD/YYYY
Missing Reason: Unknown
9 Date of last appropriate Shock MM/DD/YYYY
Missing Reason: Unknown
9 Date of Last Hgb A1c MM/DD/YYYY
Missing Reason: Unknown
9 Value of Last Hgb A1c Missing Reason: Not Done Unknown
9 Treating with Insulin NoYesUnknown
9 GI/Nutrition Failure to thrive/cachexiaFontan associated liver diseaseInfectious hepatitisProtein losing EnteropathyOther, specify
9 Hepatitis History ABCUnknownOther, specify
9 Heterotaxy/Isomerism AspleniaPolyspleniaSitus inversusUnspecifiedOther, specify
9 Malignancy Lymphoma, leukemias/p BMTs/p Chest RadiationSolid organ cancerUnknownOther, specify
9 Neurologic Anoxic brain injuryHemorrhagic and/or thromboembolic strokeOther, specify
9 Anoxic Brain Injury Date MM/DD/YYYY
Missing Reason: Unknown
9 Hemorrhagic and/or Thromboembolic Stroke,
Date Last MM/DD/YYYY
Missing Reason: Unknown
9 Peripheral myopathy/ neuromuscular disease
Becker muscular dystrophyDuschenne muscular dystrophyFreidrich's ataxiaUnspecifiedOther, specify
9 Respiratory AsthmaPlastic BronchitisTracheostomyUnknownOther, specify
9 Syndrome Cardiofaciocutaneous syndromeCostello syndromeDiGeorge (22q11 deletion)Down's/Trisomy 21EhlersDanlos SyndromeLEOPARD/Multiple LentigenesLoeysDietz SyndromeMarfan SyndromeNoonan syndromeOther Marfanlike syndromeTurner SyndromeUnspecifiedWilliams syndromeOther, specify
Renal Insufficiency Dialysis, acute (within past 30 days)
Insurance
Charitable Donation – Indicates that a company, institution or individual(s)donated funds to pay for the care of the listed patient.Free – Indicates that the listing hospital will not charge the patient for the costof the hospitalizationGovernment – Other US or state government insurance. For Example,Medicaid, Medicare, CHIP (Children’s Health Insurance Program), Departmentof VA refers to funds from the Veterans Administration or others.Private – Refers to funds from agencies such as Blue Cross/Blue Shield, etc.Self Pay – Indicates that the recipient will pay for the largest portion of the costof the hospitalization.Other – For example, funds from a foreign government. Specify foreign countryin the space provided.
Percent or Panel Reactive Antibody (closest to relisting)
9 Dialysis, chronic (>1 month duration)Dysfunction, not dialysisUnknownOther, specify
9 Specify Metabolic Disorder
9 Medical History, Mitochondrial Disorder, specify
Barth'sUnspecifiedOther, specify
10 Primary Insurance Charitable DonationFreeGovernmentPrivateSelf PayUnknownOther, specify
11a Cytotoxic PRA ie. Serum is tested against panel of lymphocytes
DoneNot Done
11a T Cell % Missing Reason: Not Done Unknown
11a B Cell % Missing Reason: Not Done Unknown
11a Date (Cytotoxic PRA) Missing Reason: Not Done Unknown
11b Cytotoxic PRA, DTE/DTT Panel performed on serum treated with DTE or DTT (or
equivalent) to reduce the IgM antibodies and identify high PRA results
presumably secondary to a drug or other causes.
DoneNot Done
11b T Cell % Missing Reason: Not Done Unknown
11b B Cell % Missing Reason: Not Done Unknown
11b Date (Cytotoxic PRA,DTE/DTT)
Missing Reason: Unknown
11c Flow Cytometry or LuminexPRA
DoneNot Done
11c Class I % Missing Reason: Unknown
11c Class II % Missing Reason: Unknown
11c Date MM/DD/YYYY
Missing Reason: Unknown
11d Relisted for prospectivecrossmatch
NoYesUnknown
11d Prospective CrossmatchType
Donor CellsDonor Cells and VirtualVirtualUnknown
11d Virtual Crossmatch Avoidance of donor antigens to all antibodiespresentAvoidance of donor antigens to antibodies aboveprespecified thresholdAvoidance of donor antigens to C1q fixingantibodies onlyUnknown
Hemodynamics Prior to ReListingIndicate the hemodynamics even if the patient is on pressors or inotropes. Best hemodynamics are those performed during theadministration of agents given specifically to lower the pulmonary arterial pressure or the pulmonary vascular resistance. All pressuresshould be listed in mmHg. If unclear, please consult with your PI.
12a Were hemodynamics done prior to relisting?
NoYesUnknown
12a Date MM/DD/YYYY
Missing Reason: Unknown
12a Fontan Mean Pressure Missing Reason: Not Done Unknown
12a RAm (RAP or CVP) Right Atrial Mean Pressure
Missing Reason: Not Done Unknown
12a PAm Pulmonary Artery Mean
Missing Reason: Not Done Unknown
12a PCW Mean Pulmonary Capillary Wedge Pressure
Missing Reason: Not Done Unknown
12a SVC Sat Oxygen Saturation in the SVC
Missing Reason: Not Done Unknown
12a AO Sat Aortic Saturation
Missing Reason: Not Done Unknown
12a Rp, PVRI Pulmonary resistance indexed to body surface
area (BSA) Woods Units x m2
wu x m2 Missing Reason: Not Done Unknown
12a Rs, SVRI Systemic resistance indexed to body surface area
(BSA) Woods Units x m2
wu x m2 Missing Reason: Not Done Unknown
12a EDP End diastolic pressure of systemic ventricle
Missing Reason: Not Done Unknown
12a C.O. Cardiac output (i.e. Qs) in L/min
L/min Missing Reason: Not Done Unknown
Schooling
Exercise Test
12a C.I. Cardiac index (i.e. C.O. divided by m2) in L/min/m2
L/min/m2 Missing Reason: Not Done Unknown
12b Was patient onmechanical support
at time of Hemodynamics
NoYesUnknown
12b Hemodynamic Agents NoYesUnknown
12b Indicate agent for best
hemodynamics
100% O2DobutamineDopamineEpinephrineIsuproterenol (Isuprel)Milrinone (Primacor)NesiritideNitric OxideNitroglycerinNitroprusside (Nipride)NorepinephrinePGE (Alprostadil)PGI (Flolan)Phenylephrine/ NeosynephrineSildenafilVasopressinOther, specify
13 Is patient in school? NoNot ApplicableYesUnknown
13 Are they at the ageappropiate level
NoYesUnknown
13 Are they in a specialeducation class
NoYesUnknown
Laboratory Values closest to time of this reportNote: labs may have been collected on different dates.
14 Was exercise test performed? NoYesUnknown
14 If test no, specify reason Age InappropriateToo SickUnknownOther, specify
14Max VO2% Predicted for Age Refers to predicted maximum VO2 for patient
(should be listed in exercise report; if not, exercise lab personnel should be able to provide this data)
% Missing Reason: Not Done Unknown
14 Respiratory Value at Peak RER or Respiratory Quotient:R Value at peak is the
respiratory quotient of carbon dioxide production divided by oxygen consumption,
and is used as an index of how vigorously the patient exercised. A value above 1.05 is generally considered to represent an adequate
effort.
Missing Reason: Not Done Unknown
14 Max VO2 Maximum oxygen consumption
ml/kg/min Missing Reason: Not Done Unknown
15 Total Bilirubin mg/dL Missing Reason: Not Done Unknown
15 Direct Bilirubin mg/dL Missing Reason: Not Done Unknown
15 AST Aspartate transaminase (also SGOT)
U/L Missing Reason: Not Done Unknown
15 ALT Alanine transaminase (also SGPT)
U/L Missing Reason: Not Done Unknown
15 BNP Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
15 Pro BNP Pro NT Btype natriuretic peptide
pg/mL or ng/L Missing Reason: Not Done Unknown
15 CRP C reactive protein
mg/dL Missing Reason: Not Done Unknown
15 Creatinine mg/dL Missing Reason: Not Done Unknown
15 BUN Blood urea nitrogen
mg/dL Missing Reason: Not Done Unknown
15 Cystatin C mg/L Missing Reason: Not Done Unknown
15 Total Protein g/dL Missing Reason: Not Done Unknown
15 Pre Albumin mg/dL Missing Reason: Not Done Unknown
15Serum Albumin g/dL Missing Reason:
Not Done Unknown
15 Cholesterol Total Cholesterol
mg/dL Missing Reason: Not Done Unknown
15 TG Triglycerides
mg/dL Missing Reason: Not Done Unknown
15 LDL Low density lipoprotein
mg/dL Missing Reason: Not Done Unknown
15 HDL High density lipoprotein
mg/dL Missing Reason: Not Done Unknown
15 VLDL Very low density lipoprotein
mg/dL Missing Reason: Not Done
© 2016 PHTS [test]
NYHA and Ross' Heart Failure
NYHA Classes
Class I: No symptoms at any level of exertion and no limitation in ordinaryphysical activity.Class II: Mild symptoms and slight limitation during regular activity.Comfortable at rest.Class III: Noticeable limitation due to symptoms, even during minimal activity.Comfortable only at rest.Class IV: Severe limitations. Experience symptoms even while at rest (sittingin a recliner or watching TV).
Ross Heart Failure Classes
Class I: No limitations or symptomsClass II: Mild tachypnea and/or diaphoresis with feeds in infants; dyspnea onexercise in older children. No growth failure.Class III: Marked tachypnea and/or diaphoresis with feeds or exertion andprolonged feeding time with growth failure.Class IV: Symptomatic at rest with tachypnea, retractions, grunting ordiaphoresis.
Unknown
16 NYHA Class 1234Not DoneUnknown
16 Ross Heart Failure Class 1234Not DoneUnknown
